Early induction of PMX-DHP improves oxygenation in severe sepsis patients with acute lung injury.

Direct hemoperfusion with polymyxin B-immobilized fibers (PMX-DHP) has been widely regarded as a treatment modality for septic shock in Japan. Recently, it was reported that PMX significantly improved the P/F (PaO2/FiO2) ratio in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). The aim of this study was to examine whether the phase of sepsis is related to the effects of PMX-DHP treatment on oxygenation in patients with ALI and ARDS. Thirty-four patients who had ALI or ARDS with severe sepsis were included in this study, and split into two groups: a high-risk for septic shock (H-R) group and a septic shock (S-S) group, based on the cut-off value at a mean arterial pressure of 60 mmHg. We analyzed the modified APACHE-II score, the sepsis-related organ failure assessment (SOFA) score, mean blood pressure (mBP), catecholamine index (CAI), P/F ratio, and 28 days mortality before and after PMX-DHP treatment. SOFA and modified APACHE-II scores showed no significant difference between the two groups. In both groups, mBP and CAI increased significantly following PMX-DHP. In the H-R group, P/F ratio increased from 194 +/- 83 to 262 +/- 113 after PMX-DHP treatment, with a statistical significance, whereas no difference was found in the S-S group. There was no difference in the 28 days survival rate between the groups. It was suggested that early introduction of PMX-DHP for severe sepsis may improve oxygenation.

Pharmacokinetics and pharmacodynamics of biapenem in critically ill patients under continuous venovenous hemodiafiltration.

To characterize the PK/PD of biapenem (BIPM) in critically ill patients under continuous venovenous hemodiafiltration (CVVHDF), we conducted a prospective, open-label study in nine adult CVVHDF patients with acute renal failure at the Critical Care Medical Center, Hiroshima Prefectural Hospital. Plasma and filtrate samples were obtained at six time points. The concentrations of BIPM in plasma and filtrate were determined by HPLC. PK parameters were analyzed using Monte Carlo simulation with MIC data. BIPM concentrations in the plasma and CVVHDF filtrate peaked at the end of infusion, and the values were similar. The drug clearance by CVVHDF and non-CVVHDF was 1.28 +/- 0.14 and 9.05 +/- 4.05 L/h, respectively. Monte Carlo simulation showed that the more administration times, there were the higher the probability. In conclusion, a dosing regimen of 300 mg BIPM q8h had a higher probability of therapeutic efficacy than q12h in patients with severe sepsis under CVVHDF.

[Case of primary racemose hemangioma of a bronchial artery with life-threatening hemoptysis].

A 22-year-old woman was admitted to our hospital because of hemoptysis and respiratory insufficiency. The chest roentgenogram and the chest computed tomogram showed infiltrative shadows in the bilateral lower lobes and mediastinal emphysema. On the second day of hospitalization, we performed double lumen endotracheal tube intubations for the repeated life-threatening hemoptysis. Bronchoscope examination revealed normal bronchus with fibrin formation. Bronchial autobiography (BAG) showed a convoluted and enlarged right bronchial artery and bronchial-pulmonary artery shunt. We diagnosed primary racemose hemangioma of a bronchial artery and performed bronchial artery embolism (BAE) of the right upper bronchial artery using coil. There was no reccurence of hemoptysis after BAE procedure. BAE with coil seems to be effective for life-threatening hemoptysis due to racemose hemangioma.

Methemoglobinemia induced by automobile exhaust fumes.

Although methemoglobinemia is an uncommon disorder, it should always be considered in the differential diagnosis of cyanosis. Major causes of acquired methemoglobinemia are nitrates, aniline, and analgesics, though rare cases have been reported to have been caused by automobile exhaust fumes. A 24-year-old man had inhaled a large amount of automobile exhaust fumes, intending to commit suicide. He had become unconscious, with dilated pupils and symptoms of cyanosis. Arterial hemoglobin oxygen saturation (Sp(O2)) was 86%, with a methemoglobin level of 44.3% and a carboxyhemoglobin level of 0%, while electrolytes, blood urea nitrogen, creatine, and glucose measurement results were normal. He was treated with methylene blue 250 mg (approximately 4 mg/kg) through a nasogastric tube. Four hours after the treatment, because the methemoglobin level was slightly above normal (2.2%), we added 180 mg of methylene blue. The results of final arterial blood gas analysis were a methemoglobin level of 0.4% and a carboxyhemoglobin level of 0.8%. He recovered uneventfully and returned home by himself the next day. To summarize, we successfully treated, with methylene blue given through a nasogastric tube, a young man who had developed severe methemoglobinemia from inhaling automobile exhaust fumes.