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【目的】救急集中治療の人生の最終段階（以下，終末期）における方針決定は倫理問題を抱えやすい。理由は突然発症し情報と時間的猶予が少ない，生命維持装置を駆使するため急性期と終末期の境界が不明瞭，意識障害などで患者が意向を示せないなどである。そのため当センターでは多職種倫理カンファレンス（inter–professional ethics conference: IPEC）を開催し，問題解決に取り組んできた。これまでに実施したIPECの内容を検証し，その有用性と課題を検討した。【対象】2016年1月1日から2018年3月31日の27か月間にIPECを行った39例。患者背景，IPEC開催日，検討メンバー，終末期の判断率，意思決定の方法，方針決定日と内容，転帰等を算出した。【結果】IPECは必要性が判断されるとほぼ同日のうちに開催された。初回のIPECで方向性が示されたのは77%であり，その後の患者家族との合意形成の過程で衝突がみられたケースはなかった。【結語】救急集中治療の現場では患者の状態変化が速く，方針決定には機動性と迅速性を要するため，IPECによる方針検討は有用であった。一方でその検討プロセスには質を確保することも重要であり，IPEC議事録兼進行マニュアルや意思決定能力評価シートといった標準化ツールなどによるクオリティーコントロールの可能性が示唆された。 Aims: Policy decisions for end–of–life acute disease and intensive care are prone to ethical problems. Due to sudden onset, information and time delays are small, and the boundary between acute phase and terminal stage that defines the need for full life supporting device use is unclear. Furthermore, patients often cannot present their intentions due to consciousness disturbances, etc. Therefore, we held an inter–professional ethics conference (IPEC) aiming to solve the problems associated with end–of–life policy decisions. We examined the contents of the IPECs that have been conducted thus far, their usefulness, and unmet challenges. Methods: We identified 39 patients for whom IPEC was performed, over 27 months (January 1, 2016 – March 31, 2018). Patient background, IPEC hosting date, review members, judgment rate of terminal period, basis of decision making, policy decision date and content, outcome, etc. were investigated. Results: Nearly all IPECs were held on the same day, when the necessity was recalled on the eighth hospital day (median). In the first IPEC, a direction was indicated in 77% cases, and there were no cases where conflicts were seen with the patient’s family during the consensus formation. Conclusions: In the acute disease and intensive care field, patient conditions change rapidly, and policy decisions require mobility and urgency; therefore, the IPEC policy review was useful. It is also important to ensure quality in the review process. Standardization tools, such as IPEC minutes combined conference proceeding manuals or decision–making ability evaluation sheets, possibly allowed us to control the quality.

65歳の男性。原因不明の発熱のため入院した。第5病日に左胸腹部の腫脹・疼痛・熱感が出現したため，壊死性筋膜炎疑いで緊急手術を実施した。肉眼的に壊死所見を認めなかったが，病理組織診で壊死性筋膜炎の診断となった。デブリードマンを追加し，抗菌薬投与を含めた全身管理を行うも，全身状態の改善は見られなかった。第23病日に白血球数の異常高値を認めたため，骨髄検査を実施，骨髄異形成症候群と診断した。再度，創部の病理組織診を施行し，Sweet症候群と診断した。ステロイドパルス療法を開始したが，呼吸不全の増悪により第30病日に死亡した。Sweet症候群は，突然の有痛性，浮腫性の紅斑性皮膚病変を特徴とした稀な炎症性疾患である。近年，皮膚病変とともに，発熱と敗血症性ショック様の壊死性筋膜炎と類似した病態を呈するnecrotizing Sweet syndromeと呼ばれるSweet症候群のsubtypeが報告されているが，デブリードマンや抗菌薬の効果は少なく，ステロイド投与が著効する。全身状態の悪化から多臓器不全に進行する例もあり，早期のステロイド投与が重要である。壊死性筋膜炎の診断で治療を開始したが，抗菌薬が効かず，培養検査が陰性の場合はSweet症候群のsubtypeであるnecrotizing Sweet syndromeを鑑別すべきである。 A 65–year–old man was admitted to our hospital for fever of undetermined origin. On day 5, he presented with swelling, pain, and a burning sensation on his left thoracoabdominal wall. Since necrotizing fasciitis was suspected, emergency surgery was performed. Macroscopically, a necrotic fascia and subcutaneous abscess were not observed. However, a necrotic fascia was suspected based on a skin biopsy. His condition continued to worsen in spite of extensive surgical debridement and administration of broad–spectrum antibiotics. On day 23, his bone marrow was analyzed due to elevated white blood cells, and he was diagnosed with Sweet syndrome. Systemic corticosteroid therapy was initiated but he died on day 30 due to progression of respiratory failure. Sweet syndrome is a relatively rare skin disease. Recently, a subtype of Sweet syndrome is reported to have symptoms closely resembling sepsis. This subtype called necrotizing Sweet syndrome is similar to sepsis with a rapid onset of a progressive cutaneous lesion. The patient with this subtype responded rapidly to systemic corticosteroids. We suggest that the diagnosis of necrotizing Sweet syndrome should be considered in all cases of suspected necrotizing fasciitis that are unresponsive to antibiotics and have negative bacterial cultures.

間歇型一酸化炭素（carbon monoxide: CO）中毒は遅発性脳症（delayed encephalopathy: DE）とも呼ばれ，治療法は確立されておらず，重度の後遺症を残す症例も多い。DEに対し，長期的な高圧酸素療法（hyperbaric oxygen therapy: HBOT）を施行し，社会復帰を得た症例を経験したので報告する。症例は30歳の女性。家族が自宅ガレージに駐車後エンジンを停止するのを忘れており，翌日上階室内で意識消失しているところを発見された。来院時，GCS 8の意識障害を認め，CO–Hb 32%で急性CO中毒と診断した。気管挿管を実施し，100%平圧酸素投与と48時間の脳低温療法を施行した。CTで淡蒼球の低吸収化，MRIで前頭葉大脳白質に高信号を認めた。その後第19病日までに意識は元の状態まで回復したが，第32病日に突然，無表情となり不隠行動と失禁がみられ，第35病日に立位や嚥下が困難となり，意思疎通も不能となった。DEを発症したと考え，2.0気圧，60分間でHBOTを開始した。3か月間で計60回行ったところ，徐々に神経所見が改善し，大きな後遺症を残すことなく退院となり社会復帰した。DEに対するHBOTの有効性を示す大規模研究はないが，本症例では長期的なHBOTが著効した印象が強く，重度のDEにおいて症状が進行しても長期治療すべき症例があると考えられた。 Delayed encephalopathy (DE) after acute carbon monoxide (CO) poisoning is a disease with a poor prognosis. There is no established treatment for DE, and no evidence that hyperbaric oxygen therapy (HBOT) is beneficial in DE. A 30–year–old female presented with severe CO poisoning. She was found unconscious and her carboxyhemoglobin level on admission was 32%. She was admitted to the intensive care unit, and immediately treated with mechanical ventilation with normobaric oxygen and brain hypothermia therapy. She regained consciousness 19 days later, and returned to her normal activities. However, 13 days later she became restless and developed incontinence. Her neurologic state began to deteriorate rapidly, progressing to akinetic mutism over the next week and finally she became less communicative. She was diagnosed with DE after CO intoxication. HBOT was conducted every day at 2.0 absolute atmosphere (ATA), each session lasting 60min, and gradual and progressive clinical improvement was observed. Her condition gradually improved over the next three months and she regained independence in her activities of daily living. She also showed significant improvement in neurocognitive function. HBOT appears useful in treating DE patients.