Importance of Diagnostic Imaging Training for Intensivists: Lessons Learned From a Case.

Intensive care physicians are tasked with managing patients with complex organ disorders, necessitating a broad skill set and ongoing education. While simulation training often focuses on equipment handling, this case report highlights a critical instance of acute aortic dissection initially missed on imaging during intensive care unit (ICU) admission. An 86-year-old woman with multiple comorbidities presented with respiratory symptoms and electrolyte imbalances, ultimately requiring ICU admission. Despite initial inconclusive imaging and treatment for suspected conditions, further evaluation revealed a dissecting aneurysm of the descending aorta. This case underscores the importance of thorough diagnostic evaluation and ongoing vigilance, especially in older adults with multiple health conditions. It emphasizes the need for comprehensive education, including proactive training in image diagnosis, to recognize diverse medical presentations and potential complications. This case serves as a reminder of the evolving challenges in critical care and the necessity for continuous education and adaptability to ensure optimal patient outcomes.

Clinical features and outcomes of in-hospital cardiac arrest in code blue events: a retrospective observational study.

Background: In-hospital cardiac arrest (IHCA) is a critical medical event with outcomes less researched compared to out-of-hospital cardiac arrest. This retrospective observational study aimed to investigate key aspects of IHCA epidemiology and prognosis in patients with Code Blue activation. Methods: This retrospective observational study enrolled patients with Code Blue events in our hospital between January 2010 and October 2019. Participant characteristics, including age and sex, and IHCA characteristics, including the time of cardiac arrest, witnessed event, bystander cardiopulmonary resuscitation (CPR), initial shockable rhythm, vital signs at 1 and 6 h before IHCA, survival to hospital discharge (SHD), and the cardiac arrest survival postresuscitation in-hospital (CASPRI) score were included in univariate and multivariate logistic regression analyses with SHD as the primary endpoint. Results: From the 293 Code Blue events that were activated during the study period, 81 participants were enrolled. Overall, the SHD rate was 28.4%, the median CPR duration was 14 (interquartile range, 6-28) min, and the rate of initial shockable rhythm was 19.8%. There were significant intergroup differences between the SHD and non-SHD groups in the CPR duration, shockable rhythm, and CASPRI score on univariate logistic regression analysis. Multivariate logistic regression analysis showed that the CASPRI score was the most accurate predictive factor for SHD (OR = 0.98, p = 0.006). Conclusions: The CASPRI score is associated with SHD in patients with IHCA during Code Blue events. Therefore, the CASPRI score of IHCA patients potentially constitutes a simple, useful adjunctive tool for the management of post-cardiac arrest syndrome.

Bronchiolitis Obliterans With Recurrent Pneumothorax After Allogeneic Bone Marrow Transplantation.

Bronchiolitis obliterans syndrome (BOS) is a non-infectious pulmonary complication that can occur in patients who have undergone allogeneic bone marrow transplantation (BMT). BOS is characterized by the irreversible narrowing and obstruction of bronchi, resulting in severe respiratory distress and poor outcomes. This case report focuses on the complex management of a patient with a multifaceted medical history. A 20-year-old man was initially diagnosed with precursor B lymphoblastic lymphoma and subsequently underwent allogeneic BMT. Nine months later, the patient was diagnosed with bronchiolitis obliterans with graft-versus-host disease, resulting in the development of BOS. Remarkably, 12 years after BMT, the patient was registered for lung transplantation. However, one year after registration, the patient developed a left pneumothorax. Despite rigorous efforts, including continuous thoracic drainage and autologous pleurodesis, the pneumothorax did not respond to treatment and required video-assisted thoracic surgery (VATS) bullectomy. The preoperative assessment revealed a challenging clinical finding characterized by the need for home oxygen therapy (5 L/min with a nasal cannula), severe Hugh-Jones classification IV-V, and marked hypercapnia (partial pressure of carbon dioxide (pCO2), 76 mmHg). Imaging studies, including high-resolution computed tomography and chest radiography, revealed hyperinflation, emphysematous changes, and bronchiectasis across all lung lobes, further complicating the patient's condition. Intraoperative management had the unique challenges of persistent hypoxia (P/F ratio 65-80), positive end-expiratory pressure of 5 cmH2O, and low tidal volumes (1.6-2.0 mL/kg) during one-lung ventilation. To address these problems, both-lung ventilation had to be performed intermittently. However, hyperventilation remained unmanageable, with maximum pCO2 values reaching 140 mmHg. Following surgery, the patient had to be admitted to the intensive care unit in an intubated state. Fortunately, the following day, the patient's condition improved markedly, his state of consciousness was clear (Glasgow Coma Scale 15) and his pCO2 level improved (66 mmHg) with spontaneous breath. This course of events allowed extubation and the patient was discharged to the general ward only two days after surgery. This case highlights the critical importance of a comprehensive preoperative assessment, including advanced imaging, when managing patients with BOS and complex pulmonary complications. Furthermore, it highlights the complexity and difficulty of perioperative respiratory management in such cases.

Effect of linezolid on platelet count in critically ill patients with thrombocytopenia.

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.

A Patient with Class III Obesity and a Body Mass Index of 70.1 kg/m² Requiring Pulmonary Artery Catheterization to Confirm the Diagnosis of Pulmonary Hypertension.

BACKGROUND Intensive care management of patients with morbid obesity has been linked to a higher mortality rate than that of the normal population and can be challenging. Obesity is a recognized risk factor for pulmonary hypertension, but it can prevent cardiac imaging. This report presents the case of a 28-year-old man with class III (morbid) obesity, a body mass index (BMI) of 70.1 kg/m², and heart failure, requiring pulmonary artery catheterization (PAC) to confirm the diagnosis of pulmonary hypertension. CASE REPORT A 28-year-old male patient with a a body mass index (BMI) of 70.1 kg/m² was admitted to the Intensive Care Unit (ICU) for the management of respiratory and cardiac failure. The patient had class III obesity (BMI >50 kg/m²) and heart failure. Due to the difficulties in evaluating hemodynamic status via echocardiography, a pulmonary artery catheter (PAC) was placed, revealing a mean pulmonary artery pressure of 49 mmHg, and a diagnosis of pulmonary hypertension was made. The alveolar partial pressures of oxygen and carbon dioxide were optimized by ventilatory management to reduce pulmonary vascular resistance. The patient was extubated on day 23 and was discharged from the ICU on day 28. CONCLUSIONS Pulmonary hypertension should be considered in the evaluation of obese patients. Using a PAC during the intensive care management of a patient with obesity could aid in the diagnosis of pulmonary hypertension as well as cardiac dysfunction, determine treatment strategies, and evaluate hemodynamic responses to various therapies.

Precision at the Bedside: Practical Efficacy of Clockwise Catheter Torque for Accurate Tip Positioning of Peripherally Inserted Central Catheters.

Precise placement of peripherally inserted central catheters (PICCs) is essential for avoiding treatment risks and ensuring the success of treatment. This is typically performed under imaging guidance, but imaging modalities may not be accessible under resource-limited settings or alternative settings such as communicable disease isolation rooms. Here, we have proposed a new technique for the precise placement of PICCs through the application of clockwise torque. Application of the PICC with this technique in our patient resulted in the precise insertion of the catheter. As this method eliminates the need for imaging modalities, it has promise for application at the bedside and in resource-limited settings. Importantly, it presents a new aspect of catheterization protocols that could hold immense potential for the future. In the future, its efficiency needs to be verified in a larger number of patients under different settings and from different populations.

Case Report: Occurrence of Thyroid Storm in a Young Patient With Recurrent Diabetic Ketoacidosis.

Background: Thyroid storm (TS) is a fatal disease that leads to multiple organ failure and requires prompt diagnosis. Diabetic ketoacidosis (DKA) is a trigger for thyroid crisis. However, TS and DKA rarely occur simultaneously. Moreover, owing to the rarity of the co-occurrence, the clinical course remains unclear. In this study, we present a case of TS that developed during the follow-up for repeated DKA in a young patient. Case Presentation: A 25-year-old man with a history of recurrent DKA was brought to the emergency room frequently with similar symptoms. DKA treatment was initiated, but his tachycardia and disturbance of consciousness did not improve. Further examination of the patient revealed a Burch-Wartofsky Point Scale score of 80 points, consistent with the Japan Thyroid Association criteria. Therefore, DKA coexisting with TS was diagnosed. Antithyroid medication, inorganic iodine, and corticosteroids were then started as treatment for TS, and ß-blockers were administered to manage tachycardia. With these treatments, the patient's health improved and he recovered. Conclusions: In severe cases of recurrent DKA, the presence of TS should be considered, and early treatment should be initiated before the patient's condition worsens.

Efficacy of Intravenous Immunoglobulin Therapy for Patients With Sepsis and Low Immunoglobulin G Levels: A Single-Center Retrospective Study.

PURPOSE: The efficacy of intravenous immunoglobulin (IVIG) administration in patients with sepsis or septic shock remains unclear. A single-center retrospective study was conducted to evaluate the association between IVIG supplementation and favorable outcomes in patients with sepsis and low serum immunoglobulin G (IgG) levels. METHODS: A total of 239 patients with sepsis were identified whose serum IgG levels were determined upon admission to the intensive care unit between January 2014 and March 2021. Patients with low IgG levels (<670 mg/dL) were divided into the IVIG and non-IVIG groups. Patient data were collected from electronic medical records to evaluate the patients' characteristics, sepsis severity, and prognosis. The primary outcome was 28-day mortality. The propensity score was calculated by using the following variables: age, Sequential Organ Failure Assessment score, immunocompromised status, and serum IgG levels. Logistic regression analysis using propensity score as the adjusted variable was performed to evaluate the outcome. FINDINGS: Of 239 patients, 87 had low IgG levels. Of these patients, 47 received IVIG therapy. The 28-day (odds ratio [OR], 0.15; 95% CI, 0.04-0.54; P = 0.004) and 90-day (OR, 0.31; 95% CI, 0.11-0.83; P = 0.020) mortality rates were significantly lower in the IVIG group than in the non-IVIG group. Moreover, the number of days free from renal replacement therapy was significantly higher in the IVIG group than in the non-IVIG group (OR, 1.06; 95% CI, 1.01-1.11; P = 0.025). Serum IgG levels in the IVIG group showed no significant difference compared with those in the non-IVIG group. No significant differences in the patients' characteristics were observed between the groups. IMPLICATIONS: This study found that IVIG administration in patients with sepsis and low serum IgG levels was associated with improved prognosis. Further studies are warranted to evaluate the validity of IVIG therapy for patients with sepsis and low serum IgG levels.

Sudden cardiac arrest associated with myxedema coma due to undiagnosed hypothyroidism: a case report.

BACKGROUND: Myxedema coma, which occurs due to hypothyroidism, is a rare and life-threatening condition. Some patients have hemodynamic dysfunction, which consequently leads to cardiac arrest. The rarity of this condition makes it difficult to determine the cause of cardiac arrest. It is important to diagnose myxedema coma based on clinical findings, including physical examination and laboratory parameters. We present a case of undiagnosed and untreated hypothyroidism that initially caused myxedema coma and then led to cardiac arrest. CASE PRESENTATION: A 56-year-old woman who had no medical history was transferred to our hospital for the management of return of spontaneous circulation due to sudden cardiac arrest. Findings of laboratory tests revealed that she had hypothyroidism. On physical examination, she was found to have a puffy face, thin eyebrows, and severe systemic non-pitting edema. Therefore, the patient was clinically diagnosed with myxedema coma, which was the cause of cardiac arrest. She was treated with thyroid hormone and hydrocortisone, resulting in improvement in her general condition, except for the neurological dysfunction. CONCLUSIONS: This case suggests that myxedema coma is caused by undiagnosed and untreated hypothyroidism, leading to sudden cardiac arrest. Our findings are useful in the differential diagnosis of hypothyroidism based on characteristic physical examination findings. Clinicians should be aware of the differential diagnosis of myxedema coma based on findings from physical examination and laboratory testing of thyroid function, and the treatment should be started immediately.

Safe Extubation of Patients with COVID-19 for Minimizing Aerosolized Droplets.

BACKGROUND: Healthcare workers must be protected during extubation of patients with coronavirus disease 2019 (COVID-19) owing to the presence of aerosolized droplets. Herein, we report a technique for extubating a patient with COVID-19 while minimizing aerosol dispersion. CASE REPORT: We retrospectively identified a total of 79 patients admitted to our hospital from February 2020 to January 2021. Six of these patients were intubated for mechanical ventilation, 2 of whom had to be extubated. We prepared a clear vinyl sheet in the shape of a tent to place over the patient, and 2 staff members, both well experienced in airway management, stood outside the tent on either side of the patient. Before extubation, we confirmed that the patient's consciousness level was good and the patient had no distress by adjusting the dose of sedative drugs. After extubation, a surgical mask was placed on the patient's face. CONCLUSION: Our experience indicates that this method of extubation in a patient with COVID-19 could be safely implemented to protect healthcare workers.

Low immunoglobulin G level is associated with poor outcomes in patients with sepsis and septic shock.

BACKGROUND: Despite studies on low immunoglobulin G (IgG) levels in critically ill patients, their association with clinical outcomes in sepsis patients remains disputed. Herein, we determined the association between low IgG levels and clinical outcomes and investigated the 28-day mortality in patients with low IgG levels. METHODS: We retrospectively identified 238 patients whose serum IgG levels were measured upon intensive care unit admission using medical record data collected between January 2013 and August 2018. We extracted data on patient characteristics, severity scores (APACHE II, SOFA score), neutrophil-lymphocyte ratio (NLR), procalcitonin levels, and serum IgG levels and calculated the cut-off value for the IgG level according to the evaluated clinical outcomes. The primary outcome was 28-day mortality. RESULTS: There were no significant differences in NLR and procalcitonin levels between survivors and non-survivors; serum IgG levels were significantly higher in survivors than in non-survivors (P = 0.004). A serum IgG cut-off value of 670 mg/dL was calculated from receiver operating characteristic curve analysis, and serum IgG levels significantly predicted survival with an area under the curve of 0.63 (95% CI, 0.54-0.72) (P = 0.004). Patients with low IgG levels (<670 mg/dL) had significantly higher mortality rates than those with normal IgG levels (≥670 mg/dL) (P < 0.001). CONCLUSION: Our results reveal that low IgG levels (<670 mg/dL) in critically ill patients are associated with poor clinical outcomes related to 28-day mortality. In patients with sepsis, low IgG levels could be a predictor of poor outcome.

The effect of recombinant human soluble thrombomodulin on renal function and mortality in septic disseminated intravascular coagulation patients with acute kidney injury: a retrospective study.

BACKGROUND: Clinical evidence showing the effectiveness of recombinant human soluble thrombomodulin (rhTM) for treating sepsis-induced disseminated intravascular coagulation (DIC) and organ dysfunction (particularly renal injury) is limited because of differences in the inclusion criteria and disease severity among patients. This study aimed to assess the association between rhTM and outcomes in septic DIC patients with acute kidney injury (AKI). METHODS: This retrospective observational study analyzed the data of patients who were admitted to the intensive care unit (ICU) of a single center between January 2012 and December 2018, and diagnosed with sepsis-induced DIC and AKI. Data were extracted as follows: patients' characteristics; DIC score, as calculated by the Japanese Association for Acute Medicine and the International Society of Thrombosis and Hemostasis criteria; serum creatinine levels; and ICU and 28-day mortality rates. The primary outcome was the dependence on renal replacement therapy (RRT) at ICU discharge. The propensity score (PS) was calculated using the following variables: age, sex, septic shock at admission, DIC score, and KDIGO classification. Subsequently, logistic regression analysis was performed using the PS to evaluate the outcome. RESULTS: In total, 97 patients were included in this study. Of these, 52 (53.6%) patients had received rhTM. The dependence on RRT at ICU discharge was significantly lower in the rhTM than in the non-rhTM group (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.19-0.97; P = 0.043). The serum creatinine levels at ICU discharge (OR, 0.31; 95% CI, 0.13-0.72; P = 0.007) and hospital discharge (OR, 0.25; 95% CI, 0.11-0.60; P = 0.002, respectively), and the 28-day mortality rate (OR, 0.40; 95% CI, 0.17-0.93; P = 0.033) were significantly lower in the rhTM than in the non-rhTM group. Moreover, the Kaplan-Meier survival curve revealed significantly lower mortality rates in the rhTM than in the non-rhTM group (P = 0.009). No significant differences in the DIC score and AKI severity were observed between the groups. CONCLUSIONS: Among sepsis-induced DIC patients with AKI, rhTM administration was associated with lower dependence on RRT at ICU discharge, improvement in renal function, and lower 28-day mortality rate.

Therapeutic Evaluation of Computed Tomography Findings for Efficacy of Prone Ventilation in Acute Respiratory Distress Syndrome Patients with Abdominal Surgery.

INTRODUCTION: In Acute Respiratory Distress Syndrome (ARDS), the heterogeneity of lung lesions results in a mis-match between ventilation and perfusion, leading to the development of hypoxia. The study aimed to examine the association between computed tomographic (CT scan) lung findings in patients with ARDS after abdominal surgery and improved hypoxia and mortality after prone ventilation. MATERIAL AND METHODS: A single site, retrospective observational study was performed at the Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan, between 1st January 2004 and 31st October 2018. Patients were allocated to one of two groups after CT scanning according to the presence of ground-glass opacity (GGO) or alveolar shadow with predominantly dorsal lung atelectasis (DLA) on lung CT scan images. Also, Patients were divided into a prone ventilation group and a supine ventilation group when the treatment for ARDS was started. RESULTS: We analyzed data for fifty-one patients with ARDS following abdominal surgery. CT scans confirmed GGO in five patients in the Group A and in nine patients in the Group B, and DLA in 17 patients in the Group A and nine patients in the Group B. Both GGO and DLA were present in two patients in the Group A and nine patients in the Group B. Prone ventilation significantly improved patients' impaired ratio of arterial partial pressure of oxygen to fraction of inspired oxygen from 12 h after prone positioning compared with that in the supine position. Weaning from mechanical ventilation occurred significantly earlier in the Group A with DLA vs the Group B with DLA (P < 0.001). Twenty-eight-day mortality was significantly lower for the Group A with DLA vs the Group B with DLA (P = 0.035). CONCLUSIONS: These results suggest that prone ventilation could be effective for treating patients with ARDS as showing the DLA.

Recombinant human soluble thrombomodulin is associated with attenuation of sepsis-induced renal impairment by inhibition of extracellular histone release.

Multiple organ dysfunction induced by sepsis often involves kidney injury. Extracellular histones released in response to damage-associated molecular patterns are known to facilitate sepsis-induced organ dysfunction. Recombinant human soluble thrombomodulin (rhTM) and its lectin-like domain (D1) exert anti-inflammatory effects and neutralize damage-associated molecular patterns. However, the effects of rhTM and D1 on extracellular histone H3 levels and kidney injury remain poorly understood. Our purpose was to investigate the association between extracellular histone H3 levels and kidney injury, and to clarify the effects of rhTM and D1 on extracellular histone H3 levels, kidney injury, and survival in sepsis-induced rats. Rats in whom sepsis was induced via cecal ligation and puncture were used in this study. Histone H3 levels, histopathology of the kidneys, and the survival rate of rats at 24 h after cecal ligation and puncture were investigated. Histone H3 levels increased over time following cecal ligation and puncture. Histopathological analyses indicated that the distribution of degeneration foci among tubular epithelial cells of the kidney and levels of histone H3 increased simultaneously. Administration of rhTM and D1 significantly reduced histone H3 levels compared with that in the vehicle-treated group and improved kidney injury. The survival rates of rats in rhTM- and D1-treated groups were significantly higher than that in the vehicle-treated group. The results of this study indicated that rhTM and its D1 similarly reduce elevated histone H3 levels, thereby reducing acute kidney injury. Our findings also proposed that rhTM and D1 show potential as new treatment strategies for sepsis combined with acute kidney injury.

Endoscopic Insertion of Nasojejunal Feeding Tube at Bedside for Critically Ill Patients: Relationship between Tube Position and Intragastric Countercurrent of Contrast Medium.

Background and Oblectives: We evaluated the success rate of endoscopically positioned nasojejunal feeding tubes and the intragastric countercurrent of contrast medium thereafter. METHOD: This retrospective observational study investigated patients who were admitted to a single intensive care unit and required endoscopic placement of a post-pyloric feeding tube between January 2010 and June 2016. The feeding tube was grasped with forceps via a transoral endoscope and inserted into the duodenum or jejunum. Thereafter, we assessed the position of the tube and the intragastric countercurrent using abdominal radiography with contrast medium. RESULTS: The tube tip was inserted at the jejunum and the duodenal fourth portion in 55.8 and 33.6% of patients, respectively. The tip of the inserted tube had moved into the jejunum of 71.7% of patients by the following day. The countercurrent rate was significantly lower among patients with a tube inserted into the duodenal fourth portion or more distal than among those with tubes inserted more proximally (8.4 vs. 45.4%, p = 0.0022). CONCLUSIONS: The endoscopic insertion and positioning of a nasojejunal feeding tube seemed effective because the rate of tube insertion into the duodenal fourth portion or more distal was about 90%. The findings of intragastric countercurrents indicated that feeding tubes should be inserted into the duodenal fourth portion or beyond to prevent vomiting and the aspiration of enteral nutrients.