Introduction: Cytomegalovirus (CMV) infection is associated with increased length of hospital stay and mortality in critically ill patients. We evaluated the efficacy of periodic monitoring of CMV antigenemia in intensive care units (ICU). Methods: During the four-year study period, CMV antigenemia tests were conducted in 341 cases. The tests were ordered by the attending physician’s decisions during the first two years (Before group), and conducted periodically once a week in the latter two years (After group). The primary outcome was the number of patients with positive antigenemia. Secondary outcomes were the number of positive cells, the duration of antiviral drug administration. Results: The number of patients with positive CMV antigenemia was significantly higher (3.75 times) in the After group than the Before group (P＜0.0001). Patients had a significantly shorter duration of antiviral drug administration in the After group than the Before group. Conclusions: Periodic monitoring of CMV antigenemia in the ICU revealed more patients with positive tests and shortened antiviral drug administration.

Objective: Plasma free-hemoglobin (PF-Hb) is a major risk factor of postoperative acute kidney injury (AKI) in pediatric cardiac surgery with cardiopulmonary bypass (CPB). This study aimed to evaluate our method of intraoperative haptoglobin administration. Methods: This retrospective study enrolled patients who underwent pediatric cardiac surgery with CPB at Kobe Children’s Hospital from May 2016 to February 2020. They were divided into two groups according to intraoperative haptoglobin administration based on the presence of macroscopic hematuria (Group C) or on the levels of PF-Hb, circulating blood volume and prime volume of the CPB circuit (Group P). To adjust for potential baseline confounders, propensity score matched analysis was performed for a selection of 81 patients in each group. Perioperative variables were compared between the two groups. Results: According to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, stages Ⅱ and Ⅲ were observed in 16 and 5 patients in Group C and P, respectively. The incidence of postoperative AKI in Group P was significantly lower than that in Group C (22% vs 43%, P = 0.0071). Postoperative increase in serum creatinine level from the preoperative baseline level was significantly smaller in Group P as compared with that in Group C. Conclusions: Intraoperative haptoglobin administration strategy, based on PF-Hb level, circulating blood volume and prime volume of the CPB circuit in each patient, has the possibility of reducing the postoperative AKI.

A 72-year-old man admitted for sigmoid colon cancer underwent long intestinal tube placement. On day 13 after insertion of the tube, the patient complained of dyspnea. Laryngoscopy revealed bilateral vocal cord paralysis. He diagnosed as nasogastric tube syndrome and a tracheostomy was performed. Vocal cord paralysis began to improve by day 12 after onset and resolved 6 months later. Colostomy closure was scheduled at 9 months after onset of paralysis and we used a supraglottic airway during the second surgery. The patient did not experience recurrence of vocal cord paralysis. For dyspnea in patients with an indwelling nasogastric tube, it is important to suspect nasogastric tube syndrome and promptly diagnose it with laryngoscopy and determine the indication for tracheostomy. To avoid recurrence of paralysis in patients with a history of nasogastric tube syndrome, care must be taken to secure the airway during subsequent surgical procedures.

Portal vein (PV) complications, such as thrombosis and stenosis, after living donor liver transplantation (LDLT) can be devastating and result in graft failure. We report two cases of PV stent placement via an ileocolic vein for early posttransplantation PV complications. Case 1 was a 62-year-old woman who underwent LDLT for nonalcoholic steatohepatitis using left lobe graft and splenectomy. A decline in PV blood flow was detected on POD 3. Hence, both PV angioplasty and stent placement were performed immediately at the stenosis site. Case 2 was a 55-year-old woman who underwent LDLT for polycystic liver disease using a right posterior segment graft. The PV blood flow was poor during the perioperative period. Therefore, repeated PV thrombectomy and stent placement were performed at the stenosis site on POD 1 and 2. PV flow improved in both cases, suggesting that PV stent placement is efficacious in treating PV complications in the early post-transplantation period.

Acquired factor V deficiency (AFVD) is a rare disease with an incidence of 1 in 1,000,000 and only about 200 cases reported in the literature. AFVD develops in response to the appearance of factor V inhibitor and is associated with a variety of factors, including treatment with bovine thrombin or antibacterial agents, surgery, cancer, infection, autoimmune disease, and blood transfusion, and may be idiopathic. Our case was a man in his 80’s who had a history of arch aortic replacement and was being treated for asymptomatic subacute infective endocarditis. Postoperatively, he developed hemoptysis with extravasation into the left bronchus from a pseudoaneurysm at the site of anastomosis of the prosthetic graft. A thoracic endovascular aortic repair was performed, and his postoperative course was good. However, his prothrombin and activated partial thromboplastin times were found to be prolonged. A cross-mixing test raised suspicion for AFVD, which meant that the patient had been at high risk of perioperative bleeding. Fortunately, his condition improved spontaneously after thoracic endovascular aortic repair. It is important to identify AFVD if there is abnormal coagulation or prolongation of prothrombin and activated partial thromboplastin times because of the risk of fatal bleeding.

The prevalence of intractable neurological diseases is increasing especially as the number of newly diagnosed elderly people has increased, which results in the aging of the patient population. In emergency cases, therefore, the opportunity to diagnose intractable diseases is also increasing. We experienced two cases diagnosed with neuromuscular diseases who were difficult to wean from mechanical ventilation after emergency transportation. Although the diagnoses were made after tracheostomy in both cases, we believe that early diagnosis contribute to either the avoidance of unexpected and sudden changes or to improved prognosis. Moreover, a definitive diagnosis reduces the financial and mental burdens on patients and their families. We suggest citing undiagnosed neuromuscular diseases as a differential diagnosis because a certain number of patients may have them. This is particularly applicable to patients who may be difficult to wean from mechanical ventilation, despite absent organic airway or lung abnormalities.

Pulmonary artery catheterization (PAC) is useful for monitoring critically ill patients. Several reports have documented that catheterization of the persistent left superior vena cava (PLSVC) has been associated with serious complications. Herein, we report inadvertent placement of a PAC in the PLSVC through the coronary sinus after mitral valve repair surgery, confirmed by transesophageal echocardiography (TEE) in the ICU. We experienced difficulty in detecting inadvertent placement of a PAC in the PLSVC by chest X-ray and pulmonary artery pressure waveform due to pre-existing cardiomegaly or the situation where percutaneous cardiopulmonary support is provided; TEE might be useful for detecting incorrect PAC insertion.

A morbidly obese man who weighed 219 kg was diagnosed with cellulitis of the left lower extremity and coronavirus disease 2019 (COVID-19) pneumonia. After admission, he developed severe respiratory failure. Although his management included intubation and a ventilator, his P/F ratio was 62. He was transferred for the purpose of introducing veno venous (VV) extracorporeal membrane oxygenation (ECMO). A drainage cannula with ultrasound guidance was placed via the right internal jugular vein, and a return cannula was placed via a groin incision right femoral vein. The circuit was de-aired and connected to the ECMO circuit. Esophageal pressure monitoring indicated that the ventilator setting was optimal positive end-expiratory pressure 25 cmH₂O. Post-tracheostomy, he was actively rehabilitation on ECMO support. He was weaned off ECMO on day 13 of admission because he tolerated a 24-hour ECMO-off trial without O₂ flow to an oxygenator. On day 30 of admission, he was transferred to the referral hospital. Although morbidly obese patients can require substantial additional medical resources and complex management, VV-ECMO is not contraindicated in them, even in patients weighing ＞ 200 kg. It was possible to manage him safely by resolving any associated problems.