Extracorporeal membrane oxygenation (ECMO) has been selected for the treatment of moribund patients with severe respiratory failure unresponsive to conventional ventilatory therapy. A high-flow veno-venous (arterial) bypass using a long-term durable pump and membrane oxygenator was utilized for oxygenation and carbon dioxide removal outside the body, which allows lung rest and provides the possibility of a cure for lung injury. The basic technique of ECMO had been established by Bartlett. ECMO has been established as a standard mode of therapy for neonatal respiratory failure. However, it had not been regarded as a standard therapy until the CESAR trial and a successful ECMO outcome for the 2009 H1N1 influenza pandemic was reported. ECMO for severe respiratory failure requires technical expertise and proper equipment in a tertial center, which means centralization is desirable for a reasonable outcome. Also, simulation technology was shown to be useful in effective training and education.

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Objective: To report outcomes of pediatric oncologic emergencies requiring intensive care. Methods: Medical records of patients admitted to the pediatric intensive care unit (PICU) with oncologic emergencies from June 2007 to December 2010 were reviewed. Results: Among 51 patients admitted to PICU, 39 had hematologic malignancies, and 16 were admitted after allogeneic hematopoietic stem cell transplantation. Thirty-four of the 51 patients were mechanically ventilated. Eight cases with hematologic malignancies died in the PICU, and the PICU mortality rate was 16%. In comparison to the PICU survivors, the non-survivors had a significantly higher pediatric index of mortality 2 score on admission to the PICU and higher prevalence of acute respiratory distress syndrome and sepsis. Conclusions: We reported outcomes of pediatric oncologic emergencies requiring intensive care. Further study is required to confirm the efficacy of intensive care in pediatric oncologic emergencies.

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A 61-year-old woman developed spontaneous retroperitoneal hemorrhage during hospitalization for adrenal failure and secondary coagulopathy. She slipped into a state of shock, and therefore, we began coagulopathy correction and performed a transcatheter arterial embolization to repair the retroperitoneal hemorrhage. Concurrently, we confirmed elevated intracystic pressure (19 mmHg), but did not detect any progressive organ dysfunction. At this stage, we decided to not perform surgical decompression because disturbance of the tamponade effect could result in rebleeding. Subsequently, the bleeding stopped and the patient achieved hemodynamic stability. Two days later, however, she developed acute kidney injury and hemodynamic instability. We performed emergency surgical decompression for abdominal compartment syndrome and hemostatic retroperitoneal packing. After the surgery, we performed open abdomen management, and her general condition stabilized. On the next day, we performed abdominal closure. Therefore, in cases of spontaneous retroperitoneal hemorrhage with intraabdominal hypertension, early definitive therapy can be safely achieved with hemostatic retroperitoneal packing and open abdomen management.

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A 29-year-old man who experienced accidental hypothermia and out-of-hospital cardiac arrest (CA) was transported to our hospital while receiving prolonged cardiopulmonary resuscitation (CPR). His body temperature (BT) on admission (146 minutes after the start of CPR) was 22.4°C, and an electrocardiogram showed ventricular fibrillation, so that extracorporeal CPR (ECPR) was immediately started 165 minutes after the start of CPR and continued for 30 hours. Simultaneously, therapeutic hypothermia was performed with a target BT of 33°C and was continued for 24 hours. A sinus cardiac rhythm was restored during ECPR. Although severe rhabdomyolysis and acute renal failure consequently occurred, his renal function recovered after renal replacement therapy for 30 days. The neurological impairment following CA also gradually improved. He was discharged with intact cerebral performance on 60^th hospital day. We experienced a case of accidental hypothermia with favorable outcome following prolonged CA who was treated with ECPR and intensive care for post-cardiac arrest syndrome.

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A 34-year-old male was diagnosed with Stevens-Johnson syndrome (SJS) after taking an over-the-counter drug containing ibuprofen. Systemic administration of high-dose corticosteroids failed to improve his clinical manifestations, and subsequently toxic epidermal necrolysis (TEN) developed. Daily plasma exchange (PE) was performed for five days. The replacement fluids were fresh frozen plasma for the first session. The remaining four sessions were selective PE employing Evacure^® EC-4A as a membrane separator. Evacure^® EC-4A theoretically removes small molecules, some of which are presumably implicated in the development of SJS/TEN, while eliminating relatively small amount of large molecules such as fibrinogen. Albumin was used as the replacement fluids for selective PE. PE and selective PE rapidly improved his mucocutaneous lesions. Selective PE using Evacure^® EC-4A with albumin as a replacement fluid might be an effective therapeutic modality and is expected to be superior to PE with fresh frozen plasma in the safety profiles and the cost-effectiveness.

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Objectives: Tachyarrhythmias are common in patients with sepsis, which is often associated with cardiac dysfunction, and severe sepsis is one risk factor of new-onset atrial fibrillation (Af). Therefore, management of new-onset Af in patients with sepsis is difficult. In this study, we retrospectively analyzed the incidence, treatment, and outcome of tachyarrhythmias in patients with sepsis. Methods: This study included patients with sepsis admitted to our ICU over a period of five years. We excluded patients who had an ICU stay within 24 hours, a history of Af, trauma, patients undergoing blood purification therapy and those with other confounding factors. We classified those with a heart rate over 130 /min as having tachyarrhythmia. Results: A total of 147 patients were included in this study. Tachyarrhythmias were detected in 63 patients (43%). The patients with tachyarrhythmias were significantly older, had higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, greater use of noradrenaline, milrinone, and showed higher in-hospital mortality than those without tachyarrhythmias. Our management of Af is based on administration of digoxin and landiolol. Sinus rhythm was successfully restored in 90% of the patients. Patients in whom sinus rhythm was not achieved had higher ICU mortality than those in whom it was achieved. Conclusions: Tachyarrhythmias occurred in 43% of patients with sepsis, and patients with tachyarrhythmias had higher in-hospital mortality. Ninety percent of Af were returned to sinus rhythm by administration of digoxin and landiolol.

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We report a case of varicella-zoster virus (VZV) reinfection associated with pharyngolaryngitis. An 80-year-old male patient suffering from rheumatoid arthritis was under treatment with steroids and antirheumatic drugs. The pharyngitis was followed by stomatitis in a few days, and within a week, a rash had appeared in the trunk area. He was admitted to our hospital with high fever and respiratory failure, and a stridor was audible in the neck area. Because of laryngeal edema, tracheal intubation was performed. Conglutinated papules and water blisters appeared in the neck and trunk, and the Tzanck test was positive. The diagnosis was varicella, and the first examination, only the immunoglobulin (Ig) G viral antibody titers were elevated; however, in the examination conducted 2 weeks later, both IgM and IgG antibody titers were elevated, which was considered to be reflective of reinfection with varicella. VZV causes varicella at the initial infection, subsequently, never develop the varicella again because of the specific immune. Adults under going immunosuppressive therapy may be at an increased risk of VZV reinfection.

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We report a case of reexpansion pulmonary edema (RPE) with severe hypoxia rescued by using additional nitric oxide (NO) inhalation. A 19-year-old man was admitted to our hospital with non-traumatic pneumohemothorax. On the first day, he underwent thoracoscopic bullectomy; however, 1 hour after surgery, he developed RPE with severe hypoxia. On admission to the ICU, his P/F ratio was 79.8. In spite of using mechanical ventilation with high PEEP, we could not stabilize his oxygenation over the next 12 hours. On the second day, we began administration of inhaled NO. About 30 minutes later, his P/F ratio increased from 72 to 128. The P/F ratio remained over 100 until the fifth day, when we terminated NO administration. This improvement in oxygenation suggested that NO induced vasodilation of pulmonary vessels and increased the blood flow only to well-ventilated areas of the lung. Therefore, additional NO inhalation may be recommended in patients with RPE and severe hypoxia, which is difficult to manage with conventional therapy.

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Kawasaki disease is a systemic vasculitis of unknown origin, which often occurs in young children. The frequency of myocarditis as a complication of Kawasaki disease is more than 50%, including asymptomatic cases, but it is rare for there to be complications of serious myocarditis requiring therapeutic intervention. However, many cases of serious myocarditis do not respond to intravenous immunoglobulin therapy, and although the number of cases is small, cases of mortality have been reported, so serious myocarditis as a complication of Kawasaki disease requires rigorous and focused therapeutic management, as a potentially life-threatening condition. We herein report on two cases of children in whom cardiogenic shock occurred, resulting from myocarditis as a complication of Kawasaki disease. There was no response to intravenous immunoglobulin therapy, and no improvement in circulation was obtained with high volumes of cardiovascular agent, but with plasma exchange, a favorable outcome was obtained. It is believed that in serious myocarditis as a complication of Kawasaki disease, plasma exchange can be considered as an effective treatment method.

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Posterior reversible encephalopathy syndrome (PRES) has been reported to occur in 3.5-5.9% of children after renal transplantation, although the precise overall frequency in the pediatric population is unknown. As with adults, high blood pressure and the use of immunosuppressive drugs are common risk factors. The blood pressure should be managed more rapidly and more strictly in children, because the autoregulation of pediatric brain circulation is more vulnerable to high blood pressure than that of adults. We identified nine patients who developed PRES. The patients' ages ranged from 2 to 10 years (median: 6.3 years). Immunosuppressive therapy had been used at the onset of the syndrome in 8 patients. An alteration of consciousness and hypertension above the 99^th percentile were observed in all patients. In the group with a poor neurological prognosis, it was difficult to manage the blood pressure, and the time during which the blood pressure was lower than the 99^th percentile was short. Our study demonstrates that the aggressive management of hypertension and underlying disease in the early phase of PRES is very important.

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[in Japanese]

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