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Quality improvement initiatives in intensive care units (ICUs) have increased survival rates. Changes in functional status following ICU care have been studied, but results are inconclusive because of insufficient consideration of the combinations of critical care procedures used. Using the Japanese administrative database including the Barthel Index (BI) at admission and discharge, we measured the changes in functional status among the adult patients and determined whether longer ICU stay or use of various critical care procedures was associated with functional deterioration. Of the 12 502 528 patients admitted to 1206 hospitals over 5 consecutive years from 2006, we analyzed data from patients aged 15 years or older who survived ICU admission in 320 hospitals. Critical care procedures evaluated were ventilation, blood purification (hemodialysis, hemodiafiltration, or hemadsorption), and cardiac support devices (intra-aortic balloon pump or percutaneous cardiopulmonary support system). Functional outcomes were determined by the difference between BI at admission and at discharge and were divided into improvement, no change, or deterioration. We compared patient characteristics, principal diagnosis, comorbidities, timing of surgical procedure, complications, days in ICU, and use of critical care procedures among the 3 categories. Associations between critical care procedures and functional deterioration were identified using multivariate analysis. Of 234 209 patients with complete BI information, 7137 (3.1%) received blood purification, 27 100 (11.7%) received ventilation, 2888 (1.2%) received blood purification and ventilation, 5613 (2.4%) received a cardiac support device, 247 (0.1%) received a cardiac support device and blood purification, 10 444 (4.5%) received a cardiac support device and ventilation, and 1110 (0.5%) received a cardiac support device, ventilation, and blood purification. Longer use of blood purification or ventilation and a longer ICU stay were associated with functional deterioration. Intensivists should be aware of the effects of critical care procedures on functional deterioration and advance the appropriate use of functional support according to each patient's condition.

In order to clarify the present status of blood purification therapy (BPT) in critical care in Japan, questionnaires investigating all the patients who were treated with BPT in 2005 were distributed. The number of patients who received BPT was 9,795, and the number of BPT performed was 11,623. The number and types of BPT treatment given are: continuous hemodiafiltration (CHDF)/hemofiltration (HDF) 5,443 (50.3%); continuous hemofiltration (CHF) 812 (7.5%); continuous hemodialysis (CHD) 877 (8.1%); simple plasma exchange 898 (8.3%); direct hemoperfusion (DHP) with polymyxin-B-coated textile (PMX-DHP) 1,625 (15.0%); DHP with activated carbon (AC-DHP) 129 (1.2%). The survival rates of patients with continuous therapies (CHDF, CHF, CHD) were as follows: multiple organ failure with CHDF 35%; sepsis with CHDF 65%; acute hepatic failure with CHDF 50%; acute renal failure with CHDF 66%; acute drug intoxication with AC-DHP 79%. In conclusion, continuous therapies such as CHDF, CHF and CHD were the most popular modes (> 65%) of BPT in Japan. The worst survival rate among diseases in critical care was found in multiple organ failure patients. The best survival rate was in those who suffered from acute renal failure., (Copyright 2010 S. Karger AG, Basel.)

The present study examined the pharmacokinetics of biapenem during continuous venovenous hemodiafiltration (CVVHDF) and assessed the pharmacodynamic exposure, based on a pharmacokinetic model, to consider biapenem dosage adaptation in CVVHDF. Biapenem (300 mg) was administered by 2-h infusion to seven critically ill patients receiving CVVHDF. The flow rates were 60 ml/min for blood, 800 ml/h for filtrate, and 600 ml/h for dialysate. The drug concentrations in plasma and filtrate-dialysate were determined by high-performance liquid chromatography and analyzed pharmacokinetically. The sieving coefficient was 0.92 +/- 0.06 (mean +/- SD). The simulation curves, using a multicompartment model, were well fitted to the measurements in plasma and filtrate-dialysate. The clearance by CVVHDF and the clearance by non-CVVHDF routes were 1.29 +/- 0.08 and 6.14 +/- 1.89 l/h, respectively. The multicompartment model was used to assess the pharmacodynamic exposure (time above the minimum inhibitory concentration of 4 microg/ml) in plasma. When the total daily dose was 600 mg, the duration of time was greater at 300 mg every 12 h than at 600 mg every 24 h. The minimum dosages needed to achieve more than 30% of the dosing interval at filtrate-dialysate flow rates of 1.4, 2.8, and 5.6 l/h were 300 mg every 12 h, 600 mg every 12 h, and 600 mg every 12 h, respectively. These results suggested that low doses or increased dosing intervals should be avoided in patients receiving this renal replacement technique. Information on pharmacodynamic exposure obtained from this model may help us to determine the appropriate biapenem dosage for CVVHDF. Moreover, our pharmacokinetic model may be useful for further pharmacokinetic studies of biapenem.

In 1994, the water quality standard of dialysate and substitution fluid for on-line HDF was established by the Kyushu Society for HDF. On the other hand, with the widespread use of high-flux membrane, reverse filtration and reverse diffusion became evident, and purification of the dialysate has become essential even for usual hemodialysis. By using ultrapure dialysate, new blood purification methods can be performed, such as internal filtration-enhanced hemodialysis, on-line HDF, and on-line HF. As a result, various clinical effects have been reported, such as improvement in anemia and in chronic inflammatory reactions. Suppression of complications involving long-term dialysis is expected, and even the prolongation of life expectancy. By using ultrapure dialysate as substitution fluid for saline solution, a fully automated dialysis machine has been developed. Furthermore, if fully automated consoles can be made smaller in size, they will contribute to the widespread use of home hemodialysis., (Copyright (c) 2004 S. Karger AG, Basel.)

Objective: To evaluate the pharmocokinetics of intravenous milrinone in patients with severe congestive heart failure during continuous venovenous hemofiltration (CVVH)., Design: Prospective study of patients with congestive heart failure admitted to the intensive care unit (ICU)., Setting: ICU between September 1997 and August 1999., Patients and Methods: Six patients with severe congestive heart failure during CVVH: all patients received a continuous infusion of milrinone of 0.25 microg x kg(-1) min(-1). The hemodynamics and plasma concentration of milrinone were measured before and after the infusion. Pharmacokinetics were analyzed with one-compartment model featuring constant rate infusion., Results: The steady-state concentration (Css) was 845 +/- 135 (mean +/- SD) ng/ml, and the half-life time (t1/2) was 20.1 +/- 3.3 h. Cardiac index and stroke volume index after the infusion of milrinone increased significantly compared with pre-infusion levels. Other hemodynamic parameters did not change significantly. All patients died within 1 month after the injection of milrinone because of severe forms of arrhythmia, such as ventricular tachycardia and ventricular fibrillation., Conclusions: We found that the mean Css and the mean t1/2 of milrinone in subjects during CVVH were much higher and longer than those previously reported for subjects with normal renal function. It is therefore essential to adjust the dose or modify the dosing interval of milrinone during renal replacement therapy for patients with severe congestive heart failure. However, further studies are needed to determine the details of pharmacokinetics of milrinone and therapeutic procedures for patients with severe heart failure during CVVH.

Five of 8 patients with rhabdomyolysis treated at our hospital following the Great Hanshin Earthquake were diagnosed with crush syndrome. One patient with crush syndrome and 3 patients with rhabdomyolysis and no renal dysfunction recovered with conservative therapy, while 1 crush syndrome patient recovered with peritoneal dialysis (PD). Of the 3 patients who died, 2 had undergone continuous arterio-venous hemofiltration (CAVH). We examined the laboratory data to identify any factors that may be prognostic for crush syndrome. The serum amylase levels were significantly higher and the levels of aspartate transaminase (AST) and lactic dehydrogenase (LDH) tended to be higher from the patients who died. Examination of the serum amylase, AST and LDH levels may be useful for assessing the prognosis in patients with crush syndrome.