Tomoaki Yatabe

Acute glycemic control significantly affects the clinical outcomes of critically ill patients. This updated network meta-analysis examines the benefits and harms of four target blood glucose levels (< 110, 110–144, 144–180, and > 180 mg/dL). Analyzing data of 27,541 patients from 37 trials, the surface under the cumulative ranking curve for mortality and hypoglycemia was highest at a target blood glucose level of 144–180 mg/dL, while for infection and acute kidney injury at 110–144 mg/dL. Further evidence is needed to determine whether 110–144 or 144–180 mg/dL is superior as an optimal glucose target, considering prioritized outcomes.

Background: Recent systematic reviews and meta-analyses have suggested that low-dose steroids are effective in the treatment of acute respiratory distress syndrome (ARDS). Recent guidelines recommend the use of low-dose steroids instead of high-dose steroids. These systematic reviews were conducted based on the concept that the effect of steroids is constant regardless of their type. We discuss whether the type of steroid used influences the outcomes in patients with ARDS. Main body: From a pharmacological standpoint, methylprednisolone has little activity as a mineralocorticoid and may cause pulmonary hypertension. The results of the rank probability of our previous network meta-analysis revealed that low-dose methylprednisolone might be an optimal treatment compared to using other types of steroids or no steroids in terms of ventilator-free days. Similarly, an analysis of individual data from four randomized controlled trials suggested that low-dose methylprednisolone was associated with decreased mortality in patients with ARDS. Dexamethasone has attracted the attention of clinicians as a novel adjunct therapy for ARDS. Conclusion: Recent evidence has shown that low-dose methylprednisolone may be an effective treatment option for ARDS. The timing of initiation and duration of low-dose methylprednisolone therapy should be verified in future studies.

Background: Anaphylactic shock of diclofenac etalhyaluronate agent can be prolonged and recurrent. However, its reports are rare, and consequently, its method of management remains to be established.Case Presentation: A 65‐year‐old woman received an intra‐articular injection of diclofenac and hyaluronate. After 20 min, systemic urticaria and severe hypotension developed after walking. After an intramuscular adrenaline injection, she was transferred to our hospital. Despite administration of continuous noradrenaline and adrenaline, hypotension persisted. Seven hours after the joint injection, 25 mL of knee joint fluid was aspirated under ultrasound guidance. Mobilization was performed 24 h after joint injection. However, urticaria rapidly spread after standing. At 45 and 46 h after joint injection, we confirmed that no symptoms, including urticaria, recurred after walking.Conclusion: Anaphylactic shock due to intra‐articular injection of diclofenac etalhyaluronate is prolonged and requires extended observation. Aspiration of joint fluid may be one of the treatment options.

The systemic immune-inflammation index (SII, platelet count × neutrophil–lymphocyte ratio) is a novel parameter for systemic inflammation. Cardiopulmonary bypass (CPB) is associated with systemic inflammatory responses. This retrospective study aimed to determine whether SII could predict postoperative atrial fibrillation (POAF) after cardiac surgery using CPB. Patients who underwent cardiac surgery using CPB between January 2020 and July 2021 were included. The primary outcome was POAF incidence within 7 days. Receiver-operating characteristic (ROC) curve analysis was used to evaluate SII ability in predicting POAF. Multivariable analysis was used to estimate the independent association between SII and POAF development. The study included 212 patients, and 90 (43%) developed POAF. The preoperative SII cutoff of 545 × 10⁹/L predicted a poor outcome with 71% sensitivity and 81% specificity. The area under the ROC curve was 0.80 (95% confidence interval [CI] 0.73–0.86). Multivariable analysis showed that SII ≥ 545 × 10⁹/L was associated with the development of POAF (odds ratio 10.2; 95% CI 5.1–20.2, P < 0.001). SII predicted POAF with a curve of 0.91 (95% CI 0.82–1.00) in patients with coronary artery bypass grafting (CABG); the corresponding value in patients without CABG was 0.75 (95% CI 0.67–0.83). Preoperative SII may be a useful prognostic biomarker for POAF in patients undergoing cardiac surgery using CPB. Moreover, preoperative SII may play an important role in predicting POAF in patients undergoing CABG.

Prolonged neurological symptoms such as “brain fog” and cognitive impairment have occurred after coronavirus disease 2019 (COVID-19) infection. In this report, we describe impaired consciousness caused by cefepime hydrochloride (CFPM) in a patient with cognitive sequalae of COVID-19. A 56-year-old male patient was diagnosed with penile abscess after COVID-19 infection, and a blood culture detected two drug-resistant Pseudomonas aeruginosa strains. Therefore, CFPM 2 g × twice/day was administered on day 71 after intensive care unit admission. Approximately 48 h after CFPM administration, the patient showed disturbances in consciousness. Contrast-enhanced computed tomography, magnetic resonance imaging, and spinal fluid examination revealed no obvious abnormalities. Therefore, CFPM-induced neurotoxicity was suspected. CFPM was discontinued and ceftazidime 2 g × three times/day was initiated. The patient's consciousness improved 30 h after the final administration of CFPM. Serum CFPM concentrations were 14.2, 21.7, 21.7, and 11.9 μg/mL on days 1, 2, and 3 after the initiation of CFPM and on the day after CFPM was discontinued, respectively. In conclusion, intensivists should pay attention to new neurological symptoms such as CFPM-induced encephalopathy in patients with prolonged neurological symptoms after COVID-19 infection.

Purpose Although the most recent systematic review and meta-analyses on acute respiratory distress syndrome (ARDS) have shown that the use of steroids decreases mortality in adult patients, its benefits and risks may differ depending on the type and dosage of the steroid. Therefore, we conducted a network meta-analysis (NMA) to compare the differences in the efficacy among different doses and types of steroids. Methods We searched MEDLINE, CENTRAL, ICHUSHI, ClinicalTrials.gov, and WHO ICTRP databases from the earliest records to March 2021 for randomized control trials, which compared steroids with placebo or conventional therapy for ARDS. Using the random-effects model, we compared various categories of steroids (high-dose methylprednisolone, low-dose methylprednisolone, hydrocortisone, dexamethasone, and no steroid) concerning hospital mortality, incidence of infection, and ventilator-free days (VFD). Results We analyzed nine studies involving adult patients (n = 1212). Although there were no significant differences between the groups in terms of the mortality and incidence of infection, the number of VFD were greater when using low-dose methylprednisolone than when not using any steroids (Mean difference: 6.06; 95% confidence intervals: [2.5, 10.5]). Moreover, the rank probability showed that low-dose methylprednisolone might be the optimal treatment, whereas using no steroid or high-dose methylprednisolone may be inferior to other treatments in terms of mortality, infection, and VFD. Conclusion This NMA suggested that the effect of steroids on the outcome in patients with ARDS might depend on the type of the steroid drug administered. Moreover, further studies are needed to identify the optimal type and dosage.

Infection during extracorporeal membrane oxygenation (ECMO) is a common complication that leads to increased mortality. Thus, antimicrobial prophylaxis during ECMO is often performed to prevent of nosocomial infections. However, the current status of antimicrobial prophylaxis during ECMO in Japan is unclear. Therefore, we conducted a national survey of members of the Japanese Society of Intensive Care Medicine (JSICM) to clarify the current status of antimicrobial prophylaxis during ECMO in intensive care units. An 11-question survey was devised to assess antimicrobial prophylaxis and surveillance practices during ECMO. A total of 253 hospitals responded. Of these, 235 hospitals were the JSICM-certified hospitals, and the response rate was 64%. A total of 96 hospitals (39%) administered antimicrobial prophylaxis during ECMO, and 17% of hospitals had a standardized protocol for antimicrobial prophylaxis during ECMO. Of these 96 hospitals, 79% used single agents. First-generation cephalosporins were the most commonly used (54%), followed by penicillins or penicillin-derived combinations (24%), second-generation cephalosporins (7%), and anti-methicillin-resistant Staphylococcus aureus agents (6%). In conclusion, our survey revealed 39% of hospitals administered antimicrobial prophylaxis during ECMO in Japan. First-generation cephalosporins were the agents most commonly used.