Objectives: There are few reports of surgical airway management (SAM) in Japanese prehospital settings. We investigated the current situation of prehospital SAM performed by physicians. Methods: We collected retrospective medical records from April 2006 to June 2011. Results: Of the 6,102 patients who received prehospital emergency care, 1,209 were intubated and 8 underwent SAM. The latter accounted for 0.66% of all airway stabilization cases. The median age of patients who underwent SAM was 67 years. The most common reason for difficulty in airway management was airway obstruction, as seen in 7 cases. The median time from patient contact to SAM completion was 17.5 min, and the median number of failed intubation attempts was 2. The intubation was likely to take a longer time with respect to the number of trials. After 28 days of airway management, 4 of 5 patients (80%) without cardio-pulmonary arrest survived. There were no complications related to prehospital SAM. Conclusions: Airway obstruction was the most common reason for SAM in prehospital settings. Although the 28-day mortality was low, it was a challenge to shorten the time taken for airway management, because performing SAM under prehospital circumstances with limited resources is time consuming.

View full abstract

A 41-year-old female with an eating disorder overdosed on 5,740 mg of paroxetine. She presented with fever, dilated pupils, increased tendon reflexes, opsoclonus, and myoclonus, and was diagnosed with serotonin syndrome. The day after admission, torsades de pointes (TdP) developed. Magnesium sulfate was administered, leading to the normalization of serum potassium and magnesium levels, but QTc prolongation persisted. The serum paroxetine level 7 days after the final administration was high. QTc interval gradually normalized as symptoms improved with the administration of benzodiazepine and cyproheptadine. This is the first reported case in which a high dose of paroxetine alone caused TdP. Paroxetine is considered to be relatively safe among selective serotonin reuptake inhibitor (SSRI). However, the dosage in the present case was markedly high. We suggest that the inhibition of CYP2D6 by the high-dose paroxetine elevated the serum concentration in a non-linear manner, causing TdP.

View full abstract

A 64-year-old, woman was prescribed antibiotics at a hospital for a common cold 5 days and 2 weeks before being transferred to our hospital because of her poor general condition. We administered early goal-directed therapy and the steroids owing to septic shock. However, she experienced cardiopulmonary arrest and was resuscitated. On the basis of the colonoscopy findings and positive test results for Clostridium difficile toxin, we diagnosed the patient with fulminant pseudomembranous colitis (PMC). Because surgical therapy is difficult under sever septic conditions, we decided to administer conservative treatment. We initiated direct hemoperfusion using a polymyxin B immobilized fiber column direct hemoperfusion (PMX-DHP), and reduced the dose of catecholamines, we discontinued catecholamines by day 3. Her general condition stabilized, and she was discharged from the ICU on day 16, and from the hospital, on day 86. Fulminant PMC has a high mortality rate, and many patients experience treatment failure despite surgical treatment. We successfully managed fulminant PMC with conservative treatment under appropriate circulation management and PMX-DHP.

View full abstract

Ventilator-associated pneumonia (VAP) due to Pseudomonas aeruginosa has a high recurrence rate. We report a case of chronic P. aeruginosa infection with recurrent episodes of VAP in a patient with acute respiratory distress syndrome, which was successfully controlled by inhaled tobramycin therapy. A 66-year-old man injured his arm at work and underwent emergency surgery. He developed acute respiratory distress syndrome complicated by VAP and required long-term mechanical ventilation. On the 57th day of ICU stay, P. aeruginosa was isolated from endotracheal aspirates. He subsequently developed recurrent episodes of VAP at short intervals, resulting in prolonged mechanical ventilation. On the 192th day of ICU stay, aerosolized tobramycin therapy was started to treat the chronic P. aeruginosa infection, after which endotracheal tube aspirates showed a rapid decrease in the density of P. aeruginosa and the episodes of VAP reduced in frequency. The patient was successfully weaned off the ventilator on the 260th day of ICU stay. Inhaled tobramycin therapy is safe and may be useful for the prevention of recurrent VAP due to P. aeruginosa.

View full abstract

Here we report a case of acute hepatic failure due to drug-induced hypersensitivity syndrome (DIHS) caused by carbamazepine. A 72-year-old woman who took carbamazepine for trigeminal neuralgia for 6 weeks developed a rash, fever, and liver dysfunction 1 week prior to admission. The carbamazepine was withdrawn the day before admission. In spite of prednisolone administration after admission, the liver failure progressed. She also underwent corticosteroid pulse therapy (methylprednisolone 1 g/day for 3 days) and plasma exchange in the ICU, but the liver function did not improve. She died of a catheter infection 31 days after admission. We consider this to be a case of atypical DIHS because the 5 main diagnostic criteria were satisfied regardless of the lack of an increased human herpesvirus 6 immunoglobulin G antibody titer. Liver failure is the leading cause of DIHS-induced death. Early diagnosis and discontinuation of the offending drug are important to suppress the progression of liver dysfunction.

View full abstract

While previous reports have shown that dexmedetomidine (DEX) does not cause withdrawal symptoms, reports on withdrawal cases are on the rise with the increasing use of prolonged DEX administration. As most of the studies on DEX were limited to small sample sizes, many aspects regarding this condition remain unknown. Here, we report five pediatric cases of DEX withdrawal symptoms. Median age was 22 months (range 4-39), median length of DEX administration was 61 hours (range 54-187), and median maximum infusion rate was 0.9μg/kg/hr (range 0.6-0.9). Withdrawal symptoms observed include tachycardia, tachypnea, hypertension, pyrexia, agitation, discomfort, sleep disturbance, tremor, and irritability. In view of these outcomes, we recommend careful consideration before prolonged DEX is administered.

View full abstract