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Linezolid (LZD) is one of the antibiotics used to treat methicillin-resistant Staphylococcus aureus. In Japan, the dose of LZD is not generally adjusted by renal function or therapeutic drug monitoring and is readily available for critically ill patients. The adverse effects of LZD include pancytopenia, especially thrombocytopenia. We investigated the effect of LZD on platelet counts in critically ill patients with thrombocytopenia during admission to the intensive care unit (ICU). Fifty-five critically ill patients with existing thrombocytopenia (platelet count < 100 ×103 /μL) who received LZD for five days or more during the period from January 2011 to October 2018 were included. Changes in platelet count and frequency of platelet concentrate (PC) transfusion were evaluated retrospectively. Mean (± standard error) platelet count prior to initiation of LZD was 47 ± 4 ×103 /uL, which increased significantly to 86 ± 13 ×103 /uL on day 15 (p<0.01). Median [interquartile range] duration of LZD therapy was 9 [8-12] days. Thirty-two patients (58.2%) required PC transfusion in the 15-day study period. The daily rate of PC transfusion decreased from 30.2% on days 1-5 to 18.2% on days 11-15. Similar tendencies were observed in patients with non-hematological and hematological disease. Thrombocytopenia in critically ill patients in the ICU did not worsen after initiation of LZD therapy, and may be considered for the treatment of MRSA in this setting.

In Japan, the dose of the new recombinant antithrombin III concentrate (rAT-gamma) is titrated according to patient body weight (BW), while conventional plasma-derived antithrombin concentrates (AT) are administered as a fixed dose. Therefore, it is anticipated that rAT-gamma could produce better treatment effects than AT. The aim of this study was to compare the organ protective effects of doses of rAT-gamma and AT administered in clinical practice for septic disseminated intravascular coagulation (DIC) and multiple organ failure. This study was performed at a single university hospital in Japan. A total of 49 patients with antithrombin deficiency secondary to septic DIC who were administered either rAT-gamma (n = 26) or AT (n = 23) were retrospectively analyzed to assess the dose of supplemental antithrombin concentrates, plasma antithrombin activity, Japanese Association for Acute Medicine (JAAM)-DIC score, and modified Sequential Organ Failure Assessment (SOFA) score on days 0, 3 and 6. The AT-equivalent dose per kg BW of rAT-gamma (equal to the initial rAT-gamma dose per kg BW divided by 1.2) was significantly higher than the dose per kg BW of AT (AT 23.4 ± 5.1 vs. rAT 28.9 ± 3.9 IU/kg/day; P < 0.001). Consequently, serial increases in plasma antithrombin levels occurred more rapidly in the rAT-gamma group (P = 0.036). JAAM DIC and modified SOFA scores revealed significantly greater improvement in the rAT versus the AT group (JAAM DIC score: P = 0.042, mSOFA score: P = 0.005). The results of this study suggest that AT supplementation adjusted for patient BW might further improve septic DIC and multiple organ failure.

Background Among damage-associated molecular patterns (DAMPs), the specific contributions of histone and high mobility group box 1 (HMGB1) levels to disseminated intravascular coagulation (DIC) and multiple organ dysfunction (MOD) remain unclear. In this study, we aimed to investigate the association between two DAMP markers, plasma histone H3 and HMGB1 levels, and concurrent DIC and Sequential Organ Failure Assessment (SOFA) score in critically ill patients. Methods Plasma levels of histone H3 and HMGB1 were prospectively quantified in 46 critically ill patients who demonstrated systemic inflammatory response syndrome, possible sepsis, and required intensive care unit (ICU) treatment. We analyzed two DAMP marker values, various plasma-inflammatory and non-inflammatory cytokine levels, acute DIC on ICU day 3, and the maximum SOFA score at 48 h after ICU admission. Results On ICU day 3, 25 patients had DIC while 21 did not. In multivariate logistic regression analysis, plasma histone H3 levels (odds ratio [95% confidence interval]: 1.17 [1.02- 1.49], p = 0.008) and TNF-α (1.006 [1.001- 1.014], p = 0.007) were significant independent factors of DIC pathogenesis. The Spearman's rank correlation coefficients for the maximum SOFA score were 0.664, 0.602, 0.348, and 0.221 for IL-8, IL-6, histone H3, and HMGB1, respectively. Conclusion In the early phase requiring intensive care, histone H3 levels exhibited a more positive association with the onset of DIC than HMGB1. Conversely, inflammatory cytokines may exert a more substantial influence on the pathogenesis of multiple organ failure in comparison to DAMPs.

Introduction The efficacy of antithrombin (AT) supplementation against septic disseminated intravascular coagulation (DIC) may depend on various pre-existing factors, particularly the AT dose and multiple organ dysfunction severity. This study aimed to identify the impactful factors for early DIC recovery. Methods Patients’ clinical records, including AT therapy and septic DIC data, were retrospectively extracted from January 2015 to December 2020. The patients were divided into those with early DIC recovery (n = 34) and those without (n = 37). Multivariate logistic regression analysis determined significant independent factors. Time-to-event analysis confirmed how these factors affected the DIC recovery time. Results The AT dose per patient body weight (odds ratio [95% confidence interval]: 2.879 [1.031-8.042], P = 0.044) and pre-existing organ dysfunction severity (0.333 [0.120-0.920], P = 0.034) were significant independent factors affecting early DIC recovery. A higher AT dose significantly shortened the DIC recovery time among patients with severe organ dysfunction (P < 0.01), but not among non-severe patients (P = 0.855). Conclusion The therapeutic efficacy of AT treatment for septic DIC might depend on the severity of pre-existing organ failure and the AT dose per patient body weight.

Since severe acute pancreatitis (SAP) involves inflammatory mediators produced by local inflammation of the pancreas that trigger a systemic inflammatory response, intensive fluid management is required to maintain hemodynamics in the early stages of the onset of SAP. Goreisan is considered to have a diuretic effect in a state of excess water and an antidiuretic effect in a state of dehydration, regulating water balance in both directions. We investigated the clinical effects of Goreisan on water balance in SAP patients. Patients and methods SAP patients admitted to our ICU within 72 hours of being diagnosed with SAP were divided into two groups: the Rikkunshito group (before October 2015) and the Goreisan group (after November 2015). Cumulative volume of fluid infusion, urine, fluid removal by CHF, nasogastric tube drainage, and water balance from day 1 to day 5 of ICU admission. Thirty patients were included. The median age was 57 (40-69) years, and 21/30 (70%) were male. The prognostic factor score in Japanese criteria for acute pancreatitis was 5.5 (3.3-7). Of the thirty patients, 14 were in the Rikkunshito group, and 16 were in the Goreisan group. There were no differences in the cumulative volume of fluid infusion, urine, fluid removal by CHF, or nasogastric tube drainage from day 1 to day 5 of ICU admission between the two groups. However, the cumulative water balance from day 1 to day 5 of admission was 4,957 ± 6,091 mL in the Rikkunshito group, whereas it was lower in the Goreisan group at 498 ± 3,918 mL (P = 0.023). Our study showed that Goreisan administration in patients with severe acute pancreatitis might improve water balance in the early phase of onset. Early administration of Goreisan at the onset of severe acute pancreatitis may regulate fluid movement between capillaries and interstitium and alleviate fluid overload due to water refill.

Post-anesthetic shivering (PAS) is common after general anesthesia and causes sympathetic excitement, followed by elevated blood pressure. Mitral valve transcatheter edge-to-edge repair (TEER) with MitraClip® (Abbott, Santa Clara, CA) increases left ventricular output resistance because of mitral valve narrowing. PAS after TEER synergistically raises cardiac load, surpassing the left ventricular working reserve and greatly increasing the risk of left ventricular failure in patients. A 64-year-old woman diagnosed with functional severe mitral regurgitation underwent implantation of MitraClip under general anesthesia and was subsequently transferred to the intensive care unit (ICU). Thirty minutes after admission to the ICU, the patient exhibited shivering, elevated blood pressure, and reduced oxygen saturation. There was no evidence of clip displacement, and the cause of this oxygenation impairment was considered to be hypertensive heart failure triggered by shivering. Noninvasive mechanical ventilation, antihypertensive medication, and body surface warming were initiated. The patient showed signs of recovery within two hours. Shivering can increase patient risk after TEER. Effective prevention of shivering is essential because TEER, along with shivering, can increase left ventricular ejection resistance, known as afterload mismatch.

Visitation restrictions for family members are problematic in intensive care management due to the COVID-19 pandemic. We analyzed the usefulness of an intensive care unit (ICU) diary about the experiences of family members of critical COVID-19 patients. Four family members of 2 COVID-19 patients participated in this report. Both patients were transferred to our ICU after 2 weeks of treatment at another ICU. An ICU diary was given to their family members post-transfer. The family members were interviewed before and after the patients’ discharge; the recorded interviews were analyzed and categorized into several clusters using a text mining method. Five categories regarding their anxious feelings were classified before the use of the ICU diary, and 3 categories were based on their positive feelings after the use of the ICU diary. Intensive care unit diaries may be beneficial for disclosing patients’ information when visitation restrictions are exercised due to the COVID-19 pandemic.

Hemophagocytic lymphohistiocytosis (HLH) during pregnancy is a rare but critical condition that is difficult to diagnose due to its complex and nonspecific presentation. We report a case of HLH in a 27-year-old woman at 32 weeks of gestation. She presented with persistent fever and liver dysfunction, leading to a suspected diagnosis of HELLP syndrome and an emergency cesarean section. However, her condition deteriorated after delivery, with the development of pancytopenia, coagulopathy, hemophagocytosis, and fatty liver. These findings raised suspicion of HLH or acute fatty liver of pregnancy (AFLP). A comprehensive diagnostic workup, including liver biopsy and genetic testing, confirmed the diagnosis of HLH. HLH during pregnancy often mimics obstetric complications such as AFLP, underscoring the importance of careful differential diagnosis.

Introduction Linezolid (LZD) is one of the antibiotics used to treat methicillin-resistant Staphylococcus aureus. In Japan, the dose of LZD is not generally adjusted by renal function or therapeutic drug monitoring and is readily available for critically ill patients. The adverse effects of LZD include pancytopenia, especially thrombocytopenia. We investigated the effect of LZD on platelet counts in critically ill patients with thrombocytopenia during admission to the intensive care unit (ICU). Methods Fifty-five critically ill patients with existing thrombocytopenia (platelet count < 100 ×103 /μL) who received LZD for five days or more during the period from January 2011 to October 2018 were included. Changes in platelet count and frequency of platelet concentrate (PC) transfusion were evaluated retrospectively. Results Mean (± standard error) platelet count prior to initiation of LZD was 47 ± 4 ×103 /uL, which increased significantly to 86 ± 13 ×103 /uL on day 15 (p<0.01). Median [interquartile range] duration of LZD therapy was 9 [8–12] days. Thirty-two patients (58.2%) required PC transfusion in the 15-day study period. The daily rate of PC transfusion decreased from 30.2% on days 1–5 to 18.2% on days 11–15. Similar tendencies were observed in patients with non-hematological and hematological disease. Conclusion Thrombocytopenia in critically ill patients in the ICU did not worsen after initiation of LZD therapy, and may be considered for the treatment of MRSA in this setting.

Background and purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM , [2017; Volume 24 (supplement 2)] https://doi.org/10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc . This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine. Methods Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members. Results A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs. Conclusions Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.