The First Successful Living Donor Liver Transplantation for Acute-on-Chronic Liver Failure Caused by Severe Acute Necrotizing Pancreatitis: A Case Report.

Liver transplantation (LT) is the only life-saving option when acute-on-chronic liver failure (ACLF) does not improve with conservative therapy. Acute pancreatitis (AP) can cause chronic liver disease progression to ACLF. However, deceased donor LT for patients with AP has had mixed results, and no consensus has been established regarding the indication for LT. We report the first successful living donor LT (LDLT) for ACLF caused by severe AP. The 38-year-old patient with alcoholic liver disease was transferred to our institute with worsening refractory ascites. During the pretransplant workup, she developed severe acute necrotizing pancreatitis, resulting in grade 3 ACLF. The patient's clinical course was further complicated by high levels of donor-specific antibodies and immune thrombocytopenia. The AP gradually improved after intensive care combined with artificial liver support. The patient successfully underwent urgent LDLT with upfront splenectomy and desensitization therapy, including plasm exchange, high-dose intravenous immunoglobulin, and anti-thymocyte globulin. No infection or recurrence of AP was observed postoperatively. We conclude that LDLT is a feasible option for ACLF patients caused by severe AP if a deceased donor is not readily available.

A novel technique for assessment of post-extubation airway obstruction can successfully replace the conventional cuff leak test: a pilot study.

BACKGROUND: Post-extubation airway obstruction is an important complication of tracheal intubation. The cuff leak test is traditionally used to estimate the risk of this complication. However, the cuff leak test parameters are not constant and may depend on the respiratory system and ventilator settings. Furthermore, deflating the cuff also be a risk factor for patient-ventilator asynchrony and ventilator-associated pneumonia. Instead of using the cuff leak test, we measured the pressure of the leak to the upper airway through the gap between the tube and glottis with a constant low flow from the lumen above the cuff without deflating the cuff and called it "pressure above the cuff." The purpose of this study was to investigate whether pressure above the cuff can be used as an alternative to the cuff leak volume. METHODS: This prospective observational study was conducted at Kumamoto University Hospital after obtaining approval from the institutional review board. The pressure above the cuff was measured using an endotracheal tube with an evacuation lumen above the cuff and an automated cuff pressure modulation device. We pumped 0.16 L per minute of air and measured the steady-state pressure using an automated cuff pressure modulation device. Then, the cuff leak test was performed, and the cuff leak volume was recorded. The cuff leak volume was defined as the difference between the expiratory tidal volume with the cuff inflated and deflated. The relationship between the pressure above the cuff and cuff leak volume was evaluated. The patient-ventilator asynchrony during each measurement was also examined. RESULTS: The pressure above the cuff was measured, and the cuff leak volume was assessed 27 times. The pressure above the cuff was significantly correlated with the cuff leak volume (r = -0.76, p < 0.001). Patient-ventilator asynchrony was detected in 37% of measurements during the cuff leak test, but not during the pressure above the cuff test. CONCLUSIONS: This study suggests that pressure above the cuff measurement may be a less complicated alternative to the conventional cuff leak test for evaluation of the risk of post-extubation airway obstruction. TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry (UMIN000039987; March 30, 2020). https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000044604.

Cervical cord injury complicated by acute mesenteric ischemia.

Acute mesenteric ischemia is a rare, life-threatening complication of cervical cord injury. This case report emphasized the importance of prompt diagnosis and treatment of this complication. A 60-year old Japanese man with no co-morbidities was diagnosed as a C2 cervical cord injury and traumatic brain injury after a fall-down trauma. He was admitted to the intensive care unit after cord decompression surgery. Nine days later, he presented tachycardia and hypotension. Ultrasound showed dilated intestines and ascites. Intestinal ischemia was suspected based on the contrast-enhanced computed tomography scan. We performed prompt surgical resection of a broad part of the small intestines. The ischemic region of the intestines was segmental and the cause was attributed to a non-occlusive mechanism. Acute mesenteric ischemia can be fatal and a delay in diagnosis leads to poor outcomes. We focus on predisposing factors in patients with cervical cord injuries and how to prevent this serious diagnosis.

Prediction of Apnea Testing Duration to Ensure Safety During Brain Death Assessment.

BACKGROUND: Apnea testing is the last step of brain death assessment. This study aimed to determine whether apnea testing is safer when performed over a shorter duration. METHODS: The medical records of 200 brain-dead donors were retrospectively evaluated. All the records were anonymously registered in the Japanese Ministry of Health, Labor, and Welfare from 1999 to 2012. The rate of [Formula: see text] increase was analyzed to calculate the duration required for apnea testing. RESULTS: At baseline, body temperature and [Formula: see text] significantly affected the increase rate of [Formula: see text]. At baseline, the apnea testing durations were 4.7 min with normal body temperature and higher [Formula: see text] ([Formula: see text] 40-60 mm Hg, body temperature 36.5°C, [Formula: see text] 400 mm Hg); further, it was 3.0 min with higher body temperature and lower [Formula: see text] at baseline ([Formula: see text] 40-60 mm Hg, body temperature 38.0°C, [Formula: see text] 100 mm Hg). CONCLUSIONS: The specific duration of apnea testing during brain death assessment may be predicted by measuring the increase rate of [Formula: see text].

Augmented teicoplanin clearance through probable adsorption onto a polymethyl methacrylate (PMMA) hemofilter during continuous venovenous hemodiafiltration.

Teicoplanin, a glycopeptide antibiotic against Gram-positive bacteria, is used during continuous venovenous hemodiafiltration (CVVHDF), though adsorption onto a hemofilter has been observed in an in-vitro study. We report a case of extensive augmentation of teicoplanin clearance by a polymethyl methacrylate (PMMA) hemofilter. A 74-year-old man (body weight 53 kg) was performed CVVHDF with the PMMA hemofilter. The effluent flow rate maintained at 600-650 mL/h. The measured teicoplanin clearance was 31.0 mL/min, and the clearance was reduced to 11.1 mL/min over the next 6.5 hours. In conclusion, we should closely monitor teicoplanin dosing during CVVHDF using a PMMA membrane hemofilter.

Pupil diameter for confirmation of brain death in adult organ donors in Japan.

Aim: The criteria for brain death in Japan include a bilateral pupil diameter of ≥4 mm. We evaluated the appropriateness of a 4-mm pupil diameter in adult brain-dead donors in Japan. Methods: We retrospectively reviewed the records of 148 consecutive adult brain-dead donors with an average age of 46 years. All records were anonymously registered to the Japanese Ministry of Health, Labour and Welfare (the Japanese Ministry of Health and Welfare before 2001) from the various designated emergency institutes that performed organ donation under brain death from 1999 to 2012 in Japan. Results: All donors had a Glasgow Coma Scale score of 3, absence of all seven brain stem reflexes, an isoelectric electroencephalogram for >30 min, and apnea as tested by the standard method. All of these examinations were repeated approximately 6 h later for confirmation. The pupil diameter (average ± standard deviation) was 6.1 ± 1.1 mm at the first assessment and 6.4 ± 1.1 mm approximately 6 h later. The 95% probability distribution as calculated by statistical analysis was 3.93-8.30 mm in the left eye and 3.88-8.28 mm in the right eye in the first assessment, and 4.25-8.58 mm in the left eye and 4.32-8.43 mm in the right eye approximately 6 h later. Conclusion: Despite the various original causes of brain death, we conclude that a pupil diameter of ≥4 mm is a reasonable criterion for brain death in adults.

Aerosolized tobramycin for Pseudomonas aeruginosa ventilator-associated pneumonia in patients with acute respiratory distress syndrome.

BACKGROUND: Ventilator-associated pneumonia (VAP) due to Pseudomonas aeruginosa has a high mortality and recurrence rate, especially in patients with acute respiratory distress syndrome (ARDS). Therefore, new therapeutic strategies against severe pneumonia are needed. This study evaluated the efficacy of aerosolized tobramycin for P. aeruginosa VAP in ARDS patients. METHODS: A retrospective analysis was performed on patients who developed VAP caused by P. aeruginosa during the course of ARDS at the intensive care unit (ICU) of Kumamoto University Hospital. Aerosolized tobramycin inhalation solution (TIS) 240 mg was administered daily for 14 days in addition to systemic antibiotics. RESULTS: A total of 44 patients (TIS group, n = 22; control group, n = 22) were included in the analysis. No significant differences were found between the two groups in terms of clinical characteristics, including acute physiology and chronic health evaluation II score upon ICU admission. The TIS group had significantly lower recurrence of P. aeruginosa VAP (22.7% vs. 52.4%, P = 0.04) and ICU mortality (22.7% vs. 63.6%, P < 0.01) than the control group. Bacterial concentration in tracheal aspirate (mean log 10 cfu/mL ± SD on days 2-5: 1.2 ± 1.3 vs. 5.0 ± 2.3, P < 0.01) decreased more rapidly and markedly in the TIS group compared with the control group. CONCLUSION: Aerosolized tobramycin was an effective therapeutic strategy for P. aeruginosa VAP patients with ARDS.

Healthy baby delivered vaginally from a brain-dead mother.

Case: A pregnant (20 gestational weeks) 32-year-old woman was found in cardiac arrest. Spontaneous circulation returned after 15 min. She became brain dead on the 13th hospital day. The patient was in stable circulatory condition under nasal desmopressin and 20-30 mg/day of hydrocortisone. On the 92nd hospital day at gestational week 33 + 3 days, natural labor began and a healthy 2,130-g girl (Apgar 6/8) was delivered vaginally with minimum assistance. Outcome: The baby was discharged 40 days after birth and followed up regularly. Conclusion: Brain death remains a hopeless condition for patients, but a brain-dead woman may still be able to naturally deliver a healthy baby.

A validation of presepsin levels in kidney dysfunction patients: four case reports.

Here, we measured presepsins (PSPs) in four patients with acute kidney injury (AKI) or chronic kidney disease (CKD) and discuss the relationship between PSP and kidney dysfunction. Case 1: an 83-year-old man was admitted to the ICU to manage postoperative respiratory failure with AKI. He had undergone resection for rectal cancer and ileal conduit replacement. On day 1 in the ICU, Escherichia coli (E. coli) was isolated by urine culture. PSP level (pg/ml) on day 2 was 2,745 without elevation of other conventional biomarkers. On day 6, the patient was diagnosed with severe sepsis, and E. coli was isolated by blood culture. By then, PSP had risen to 3,977, along with elevation of other conventional biomarkers. His kidney function recovered gradually after continuous administration of hemodiafiltration; however, PSP continued to rise up to 6,051, along with high systemic inflammatory response syndrome (SIRS) and Acute Physiology and Chronic Health Evaluation (APACHE) II values. The patient expired on day 13 due to multiple organ failure. Case 2: a 78-year-old woman with CKD on hemodialysis (HD) was admitted to the ICU after cardiovascular surgery. Continuous HD was administered postoperatively, and PSP ranged from 1,473-1,870 without signs of sepsis. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 3: a 74-year-old woman with CKD on HD was admitted to the ICU after neurosurgery. She underwent intermittent HD postoperatively, and PSP ranged from 1,240-1,935 without sepsis symptoms. Temporary elevation of other conventional biomarkers was observed postoperatively. Case 4: a 62-year-old man with CKD was admitted to the ICU to control gastrointestinal bleeding. PSP was 606 without signs of infection or elevation of other conventional biomarkers. In cases 2, 3, and 4, bacteria were not isolated in blood cultures. Patients' clinical prognoses were good, with low or moderate SIRS and APACHE II scores. PSP in kidney dysfunction patients will be high despite non-infectious conditions. Therefore, evaluation of PSP in kidney dysfunction patients will be difficult. Further investigation is needed to clarify the relationship between PSP and kidney dysfunction.

Electrocardiogram findings of patients with serum potassium levels of nearly 10.0 mmol/L: a report of two cases.

CASES: In Case 1, a 63-year-old woman was admitted with muscular weakness. She had hypertension, diabetes mellitus, and chronic renal failure on hemodialysis. She was taking a beta-blocker. Her pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 9.8 mmol/L; electrocardiogram revealed widening of the QRS complex (0.256 s). In Case 2, a 59-year-old man was admitted with muscular weakness. He had hypertension and chronic renal failure, and was taking a renin-angiotensin-aldosterone system inhibitor. His pulse rate was 42 b.p.m. (irregular rhythm); serum potassium level was 10.1 mmol/L; electrocardiogram revealed widening of the QRS complex (0.180 s). OUTCOME: Life-threatening arrhythmia did not occur, and patients survived under appropriate treatment. CONCLUSION: Chronic renal failure, diabetes mellitus, or medications affecting extrarenal potassium homeostasis can produce a tolerance to hyperkalemia. This tolerance may help prevent life-threatening arrhythmia despite fatal levels of serum potassium.

Fulminant myocarditis survivor after 56 hours of non-responsive cardiac arrest successfully returned to normal life by cardiac resynchronization therapy: a case report.

A 20-year-old female survived fulminant myocarditis with 56 hr of non-responsive cardiac arrest and was able to resume a normal life with cardiac resynchronization therapy(CRT). On admission, she had developed cardiogenic shock refractory to pharmacological intervention. Percutaneous cardiopulmonary support was initiated with intraaortic balloon pumping. She developed complete cardiac standstill unresponsive to ventricular pacing. After 56 hr of cardiac arrest, ventricular fibrillation occurred and her ventricle started to respond to pacing therapy. She could leave the intensive care unit, although she continued to have severe heart failure refractory to medical intervention. She presented with paradoxical ventricular motion with a low cardiac output, so CRT was performed. After the initiation of CRT, her heart failure symptoms improved and she could return home.