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We investigated whether an early-phase prothrombin time-international normalized ratio (PT-INR) is an interventional prognostic indicator for patients with acute liver injury, including acute liver failure.This was a multicenter retrospective observational study. We included 595 patients with alanine aminotransferase levels ≥300 U/L due to acute liver injury who were admitted to Kagoshima University Hospital or other collaborative investigation organizations between January 1, 2010, and December 31, 2015. Patients with alanine aminotransferase levels ≥300 U/L and no previous liver disease were defined as having an acute liver injury. Acute liver failure was defined by PT-INR ≥1.5 with or without hepatic encephalopathy in acute liver injury patients. Data were obtained retrospectively from case reports and analyzed.The PT-INR on day 1 was the most accurate independent prognosis predictor in patients with acute liver injury and acute liver failure. On day 1, the transplant-free survival rates were significantly lower in patients with PT-INR ≥1.3. The transplant-free survival rates were also significantly higher in patients with acute liver injury and acute liver failure, in whom the PT-INR had recovered from ≥1.3 on day 1 to1.3 by day 8.Early-phase changes in the PT-INR can predict the prognosis of patients with acute liver injury and acute liver failure. Furthermore, PT-INR ≥1.3 could be an interventional marker, whereas PT-INR1.3 after 1 week could reflect prognostic improvement.

Background Histological examination is useful for the diagnosis of acute severe (fulminant) autoimmune hepatitis (AIH), but it is sometimes difficult to perform liver biopsy due to the complicated coagulopathy and ascites. We have shown that heterogeneous hypoattenuation on unenhanced computed tomography (CT) is a characteristic imaging feature of acute severe (fulminant) AIH. In the present study, we examined the utility of the imaging feature by applying the score to diagnose acute severe (fulminant) AIH. Methods Twenty-three patients with acute severe (fulminant) AIH were analyzed retrospectively. Modified AIH score was created by adding 3 points to AIH score with/without histological points in case of the presence of heterogeneous hypoattenuation on unenhanced CT. Results Areas of hypoattenuation were present in 15 (65%), all of which were heterogeneous pattern. Five patients (22%) were diagnosed as “definite” AIH, 16 (69%) as “probable” and 2 (9%) as “non-diagnosis” by the revised original score without histological score. By adding 3 points, 2 of “non-diagnosis” changed to “probable” AIH, and all patients were diagnosed as AIH. Conclusions Modified AIH score using heterogeneous CT image finding would be beneficial especially for patients in whom histological examinations cannot be performed because of complications. This article is protected by copyright. All rights reserved.

Aim There are no beneficial therapies except for emergency liver transplantation for acute liver failure (ALF). However, in Japan, which has a serious problem in the shortage of donor livers, therapies other than transplantation must be further investigated for patients with ALF. Pro-inflammatory cytokines promoting tissue destruction are predominant at an early phase of ALF. Corticosteroid (CS) influences monocyte/macrophage differentiation, by suppressing pro-inflammatory genes, indicating CS treatment might be beneficial during the early phase of ALF. Our aim was to elucidate the efficacy of CS pulse therapy in decreasing pro-inflammatory cytokine levels in the early stage of ALF. Methods Ten consecutive adult Japanese patients with fulminant hepatitis in the early stage, three treated with artificial liver support (ALS) and CS pulse therapy (ALS + CS group) and seven treated with ALS (ALS group), were enrolled. Clinical and biochemical data on admission were matched between the groups and retrospectively analyzed for serum concentrations of interleukin-6, tumor necrosis factor-α, and interleukin-1β over a 2-week period. Results Mean cytokine levels on admission were not different between the two groups. Tumor necrosis factor-α was significantly reduced on day 7 in patients with CS. Serum levels of pro-inflammatory cytokines tended to be reduced in patients with CS compared to those without during the observation period, although the differences were not significant. Conclusions It might be possible that introduction of CS pulse therapy in the early stage of ALF could reduce levels of pro-inflammatory cytokines, which might inhibit the cascade of progression of ALF.

Aim To investigate the clinical utility of interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) as predictive markers in consideration of the time-course changes in critically ill patients with organ dysfunction. Methods Serum levels of IL-6, PCT, CRP, and Sequential Organ Failure Assessment (SOFA) scores were measured sequentially in 92 patients during their initial 5 days following admission to the intensive care unit. Maximum values were analyzed. Patients were assigned to a low ( ≤ 8), intermediate ( > 8 and ≤ 16), or high ( > 16 and ≤ 24) SOFA score group. Results There were significant differences in the maximum serum levels of IL-6 and PCT among the three SOFA score groups (IL-6, P < 0.0001; PCT, P = 0.0004). Specifically, comparisons between the groups revealed significant differences in IL-6 levels (low versus intermediate, P = 0.0007; intermediate versus high, P = 0.0010). The probability of patients with the maximum value was greatest on day 1 (56.5%) for IL-6, on day 1 (39.1%) or day 2 (38.0%) for PCT, on day 3 (39.1%) for CRP, and on day 1 (43.5%) for SOFA score. The median (interquartile range) peak day of IL-6 was day 1 (1–2), which was significantly earlier than that of SOFA score at day 2 (1–3) (P = 0.018). Conclusion Serum levels of IL-6 reflected the severity of organ dysfunction in critically ill patients most accurately compared to PCT and CRP. Interleukin-6 elevated soonest from the insult and reached its peak earlier than SOFA score.

Background Corticosteroid (CS) has been introduced in most of acute liver failure (ALF) patients for the purpose of suppressing pro-inflammatory cytokines in Japan where a shortage of donor livers exists, whereas CS use is evaluated to be no benefit in Western countries. In the present study, we aimed to clarify the association between infectious complications and CS use in ALF, and determine when to evaluate treatment response and consider the timing for switching to liver transplantation (LT). Methods CS was administered to patients in the early stage prospectively. Clinical and biochemical features of 110 adult patients were analyzed. Results CSs were administered to 78 (71%) patients. The duration between start of CS and onset of infection was 17 ± 10 days. Multivariate analysis revealed that infection was associated with age > 50 y/o (p = 0.034) and T-BIL > 15 mg/dl (p

Background The prognosis of non-shockable out-of-hospital cardiac arrest is worse than that of shockable out-of-hospital cardiac arrest. We investigated the associations between the etiology and prognosis of non-shockable out-of-hospital cardiac arrest patients who experienced the return of spontaneous circulation after arriving at hospital. Methods and Results All subjects were extracted from the SOS-KANTO 2012 study population. The subjects were 3,031 adults: (i) who had suffered out-of-hospital cardiac arrest, (ii) for whom there were no pre-hospital data on ventricular fibrillation/pulseless ventricular tachycardia until arrival at hospital, (iii) who experienced the return of spontaneous circulation after arriving at hospital. We compared the patients' prognosis after 1 and 3 months between various etiological and presumed cardiac factors. The proportion of the favorable brain function patients that developed pulmonary embolism or incidental hypothermia was significantly higher than that of the patients with presumed cardiac factors (1 month, P

Background Autoimmune hepatitis (AIH) is one of major etiologies of acute liver failure (ALF), and the survival rate without liver transplantation (LT) of patients with fulminant AIH is especially poor worldwide. We investigated the clinicopathological features of infectious complications in autoimmune ALF retrospectively and tried to determine when to continue corticosteroid (CS) treatment or abandon it for LT. Methods Twenty patients with autoimmune ALF, comprising five severe hepatitis, 13 fulminant hepatitis and two late onset hepatic failure, were analyzed. Results Corticosteroids were administered to 19 patients. Seventeen infectious complications were observed in 12 patients. The median (range) duration between the introduction of CS and onset of infection was 15 (10–41) days. There were no significant differences in clinicobiochemical features between patients with and without infection. Of 20 patients, eight (40%) recovered without LT, four (20%) received LT and eight (40%) died without LT. Dead or transplanted patients had more advanced liver failure on admission than recovered ones (P

Case A 19-year-old man with a hemangioma that extended from the left arm to the axillary region had deteriorated due to shock, and no improvement was observed after fluid resuscitation. His status on arrival led to complications of hemorrhagic and septic shock with his left arm swollen and deep purple in color. Left arm amputation to control the source of bleeding and infection was thought to be indicated, however, the coagulation system had collapsed. Therefore, initial reduction of the blood flow to the hemangioma with angiographic endovascular treatment was carried out. Thereafter, continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter against hypercytokinemia was introduced in the intensive care unit for damage control, which resulted in success. Outcome We completed the arm amputation, and subsequently carried out a latissimus dorsi muscle flap transfer on the amputated stump. The patient achieved an ambulatory discharge. Conclusions We successfully treated the very rare case of massive venous malformation with shock due to hemorrhage and infection by performing damage control.

Aim Multiple lines and tubes often complicate bed transfer in critically ill patients. To solve this problem, the authors developed medical equipment attached to a transfer board (“transfer board tree”) that integrates the patient, transfer board, and medical equipment. The objective of this study was to evaluate the efficiency and safety of the transfer board tree. Methods Forty mechanically ventilated patients (20 transfer board tree, 20 conventional) in the intensive care unit who were transported for computed tomography were enrolled. Transfer times and adverse events were recorded. Results Transfer board tree patients had significantly shorter transfer times. There were two adverse events only in the conventional group. Conclusions The transfer board tree enables rapid intrahospital transport of intensive care patients with sufficient monitoring.

Aim To assess the clinical benefits of introducing a medical emergency team system for early medical intervention in hospital care. Methods This prospective analysis included all cases of medical emergency team activation during the first year after the introduction of the medical emergency team system at Chiba University Hospital (Chiba, Japan) in February 2011. The rates of in-hospital mortality and unexpected events before and after introduction of the medical emergency team system were compared. Results The total number of medical emergency team activation calls was 83 (4.9 per 1,000 admissions). The activation of the medical emergency team system was requested most frequently from the general ward (56.6%) and by a physician (57.8%), with the most important reasons for activation being cardiac arrest (37.3%), breathing abnormality (33.7%), and impaired consciousness (32.5%). The most frequent medical interventions by the medical emergency team were intubation (43.3%) and oxygen inhalation (41.0%). Approximately one-half of the patients requiring activation of the medical emergency team system were critically ill and needed subsequent intensive care unit admission. Although no significant difference was observed between the pre- and post- medical emergency team in-hospital mortalities (2.1% versus 2.0%, respectively), the incidence rate of serious events significantly decreased (12.4% versus 6.8%, respectively; P = 0.015). Conclusion Most patients requiring activation of the medical emergency team system were critically ill and needed emergency treatment at the location of the medical emergency team activation, with subsequent critical care. Although the introduction of the medical emergency team system did not affect the in-hospital mortality rate, it reduced the incidence of unexpected serious adverse events, suggesting that it may be clinically useful.

Background There has existed important differences in the definition of acute liver failure (ALF) between Japanese criteria and those of other countries. The novel diagnostic criteria for ALF in Japanese patients were established by the Intractable Hepato-Biliary Diseases Study Group of Japan, in order to correspond to those for ALF in Europe and the USA. We prospectively diagnosed our ALF patients based on this novel criteria, and discussed the etiology by a fixed point observation. Methods We investigated the etiology of 54 adult inpatients and outpatients with ALF between 2010 and 2012. Results Of 54 patients, 36 were ALF without coma, 17 ALF with coma and one late onset hepatic failure. The etiology was due to viral infections in 38.9%, autoimmune hepatitis in 11.1%, drug-induced liver injury in 13.0%, etiologies without hepatitis in 29.6% (circulatory disturbance in 18.5%, infiltration of the liver by malignant cells in 7.4%, and metabolic diseases in 3.7%) and indeterminate causes in 7.4%. Conclusions Circulatory disturbance was the most frequent etiology according to the novel criteria. Indeterminate etiology was less observed in our study than the nation-wide survey with significance (P = 0.0014).

Aim Older age has been widely believed to be associated with a poor prognosis of acute liver failure. We aimed to evaluate the impact of older age on outcomes of Japanese patients with severe and fulminant hepatitis in an era of a highly aging society. Methods We investigated 105 consecutive adult patients with fulminant hepatitis (FH) or severe hepatitis (SH) admitted to our liver unit between 2000 and 2013, consisting of 14 elderly patients (≥65 years) and 91 younger ones (

The short-term prognosis of patients with severe acute exacerbation of chronic hepatitis B (CHB) leading to acute liver failure is extremely poor. We have reported the efficacy of corticosteroid in combination with nucleoside analogue in the early stages, but virological efficacy has not been documented. Our aim was to elucidate the virological efficacy of this approach. Thirteen patients defined as severe acute exacerbation of CHB by our uniform criteria were prospectively examined for virological responses to treatment. Nucleoside analogue and sufficient dose of corticosteroids were introduced as soon as possible after the diagnosis of severe disease. Of the 13 patients, 7 (54%) survived, 5 (38%) died and 1 (8%) received liver transplantation. The decline of HBV DNA was significant between the first 2 weeks (P = 0.02) and 4 weeks (P < 0.01). Mean reduction in HBV DNA during the first 2 weeks was 1.7 ± 0.9 log copies per mL in overall patients, 2.1 ± 0.8 in survived patients and 1.2 ± 0.9 in dead/transplanted patients. The decline of HBV DNA was significant between the first 2 weeks (P = 0.03) and 4 weeks (P = 0.02) in survived patients, but not in dead/transplanted patients. Our study shows that corticosteroid treatment in combination with nucleotide analogue has sufficient virological effect against severe acute exacerbation of CHB, and a rapid decline of HBV DNA is conspicuous in survived patients.

Aim Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction and potentially progresses to fatal thrombosis. The 4Ts scoring system has been reported as a clinical pretest for HIT. However, its usefulness in critically ill patients has not yet been thoroughly examined. Thus, we evaluated the clinical usefulness of the 4Ts score in the diagnosis of HIT in critically ill patients. Methods One hundred and four critically ill patients who were admitted to our intensive care unit and who underwent the antiplatelet factor 4/heparin complex antibodies (PF4/heparin Ab) test with suspected HIT were enrolled in the study. The primary endpoint variable was the 4Ts score. The secondary endpoint variables were laboratory data, length of stay, and mortality, compared between thePF4/heparin Ab positive and negative groups. Results There was no significant difference in the 4Ts scores between the PF4/heparin Ab positive and negative groups. The positive predictive value (HIT patients/4T high score patients) was 15.4% (2/13), the negative predictive value (non-HIT patients/4T low score patients) was 87.5% (42/48), and the false-negative rate for the 4Ts score (4T low score patients/HIT patients) was as high as 54.5% (6/11). The PF4/heparin Ab positive patients had longer stay in intensive care compared to the PF4/heparin Ab negative patients (P = 0.035). Conclusions The present study showed the discrepancy between the 4Ts score and PF4/heparin Ab. When HIT is suspected in critically ill patients, an immediate HIT antibody test and initiation of therapeutic management of HIT are required regardless of the 4Ts score.

AIM Acute liver failure (ALF) is a worldwide problem despite its rare incidence because of its extremely high mortality. There are no beneficial therapies except for emergency liver transplantation for ALF. However, in Japan where the problem of a shortage of donor livers still remains, therapies other than transplantation must be further investigated for patients with ALF. Our aim was to elucidate the efficacy of high-dose corticosteroid (CS) in decreasing liver enzyme levels in the early stage of ALF. METHODS Thirty-one consecutive Japanese patients with viral ALF in the early stage were prospectively examined for their clinical and biochemical features and treatment responses during 2 weeks after the start of treatment. Nineteen were treated with high-dose methylprednisolone, and 12 having clinical and biochemical backgrounds with no significant difference were treated without CS. RESULTS The aspartate aminotransferase : alanine aminotransferase ratio became lower in patients treated with CS than in controls (P

Aim: After the establishment of the international criteria of autoimmune hepatitis (AIH) in 1999 and the recognition of acute onset AIH, the diagnosis of patients with fulminant type of AIH came to be made. We diagnosed autoimmune fulminant liver failure based on the criteria, and discussed the etiology of fulminant hepatitis (FH) and late onset hepatic failure (LOHF), and the characteristics of autoimmune fulminant liver failure. Methods: We investigated the etiology of 95 consecutive adult patients with FH or LOHF admitted to our liver unit between 1990 and 2009. Clinical and biochemical features, therapies and outcomes were examined in patients with AIH after 2000. Results: Of 95 patients, 85 were FH and 10 LOHF. The etiology was due to viral infections in 51.6% (hepatitis A virus in 7.4%, hepatitis B virus in 43.2% and hepatitis E virus in 1.1%), AIH in 15.8%, drug allergy-induced in 12.6%, and unknown causes in 20.0%. The rate of patients with AIH increased significantly between 2000 and 2009 compared to the rate between 1990 and 1999 (P = 0.002). In recovered patients with AIH without transplantation after 2000, coma grade was lower, alanine aminotransferase level, prothrombin time activity and alfa-fetoprotein level were higher than in the others with statistical significance. Conclusion: AIH is not a rare cause of FH and LOHF, and the number of patients with unknown causes would surely decrease in concert with the precise diagnosis of AIH.

Case We describe a case of a 22-year-old woman with alteration in consciousness and aphonia due to vocal cord impairment after carbon monoxide exposure. Brain magnetic resonance imaging revealed high signal intensity in bilateral globus pallidus and the pars reticulata of the substantia nigra on T2- and diffusion-weighted images. Laryngeal fiberscopy showed bilateral immobilization of the vocal cords in median position during both inspiration and phonation. Although the effects of hyperbaric oxygen therapy remain ambiguous, these symptoms and magnetic resonance imaging findings subsided. Outcome Aphonia due to vocal cord impairment, as a presenting symptom of carbon monoxide poisoning, has not been previously reported. We considered the cause of aphonia was vocal cord abductor paralysis or dystonia of intralaryngeal muscles after the carbon monoxide exposure. Conclusion Even though aphonia is an unusual symptom in a patient with carbon monoxide poisoning, it must be taken into consideration.

Acute disseminated encephalomyelitis (ADEM) is a demyelinating disease of the central nervous system associated with significant morbidity and mortality. High-dose corticosteroid administration has been considered the mainstay of treatment for ADEM; however, some patients with ADEM are refractory to steroid therapy. We report a case of a 17-year-old man suffering from ADEM who did not respond to corticosteroid therapy, but who exhibited a dramatic recovery with plasmapheresis. He became comatose, requiring ventilatory support, and exhibited abnormalities of some brainstem reflexes prior to treatment. He underwent sequential courses of plasma exchange therapy for three days. Plasma exchanges were carried out with concomitant continuous hemodiafiltration (CHDF) to control intracranial pressure by stabilizing pH, plasma Na+ concentration, and colloid osmotic pressure. After plasma exchanges, his reflexes and level of consciousness gradually improved. Eleven months after this treatment, he had only minimal neurological deficit that did not interfere with any of his activities of daily living. The efficacy of plasmapheresis for ADEM has not yet been established. Plasmapheresis may be indicated for ADEM, not only for patients with severe disease in whom high-dose corticosteroid treatment has failed, but also as first-line treatment for ADEM. Early initiation of plasmapheresis appears to be associated with moderate to marked improvement. Early recognition and early treatment of ADEM are thus of paramount importance.

はじめに:重症敗血症に酷似した病態を呈したSweet症候群の1例を経験したので報告する。症例:患者は32歳の女性。ICU入室11日前に男児を出産。その際に会陰切開施行される。翌日より39℃の発熱,血液検査上炎症反応を認めた。創感染を疑い,抗菌薬投与開始。またICU入室5日前頃より注射施行部に有痛性隆起性紅斑を認めた。抗菌薬投与を継続するも血圧低下,両側肺浸潤影を伴う呼吸状態の悪化を認め,敗血症,敗血症性ショック,敗血症性ARDS (acute respiratory distress syndrome)の疑いで,ICU入室となった。第2 ICU病日に骨盤部CT検査施行。骨盤内膿瘍が疑われ,同日ドレナージ術施行。ドレナージ液も含め各種培養検査を施行するも結果は全て陰性であった。感染症以外の疾患の存在を疑い,注射施行部に認められた有痛性隆起性紅斑に関し皮膚科医にコンサルテーションしたところ,Sweet症候群と診断された。そしてこの重症敗血症様の病態もSweet症候群に関連するものと判断された。第4 ICU病日よりSweet症候群に対してステロイドパルス療法を施行。その後すみやかに呼吸状態改善,炎症反応低下。第8 ICU病日に退室となった。考察:Sweet症候群は発熱,白血球増多などの炎症所見を呈し,かつ皮膚に有痛性隆起性紅斑を認める比較的まれな原因不明の皮膚疾患である。文献的には本症例のように重症敗血症に酷似した病態を呈したSweet症候群報告例はいままでに2例のみであり,稀な症例であった。病因は不明であるが,病理所見上好中球の増多,活性化が特徴的であり,好中球の活性,遊走に関わるG-CSF (granulocyte colony-stimulating factor)などのcytokineの関与が考えられている。治療としては感染症様症状を呈するも抗菌薬に全く反応せず,ステロイドが著効を示す。そのため,早期の診断,早期のステロイド投与が肝要である。結語:重症敗血症に酷似した病態を呈したSweet症候群の1例を経験した。感染症が疑われるが,抗菌薬に不応で,培養検査が陰性の症例はSweet症候群である可能性がある。

Continuous hemodiafiltration (CHDF) is an essential procedure in critical care. However, application of this therapy to pediatric patients is associated with several problems derived from their smaller body size and weight compared with adults. We have successfully conducted CHDF in pediatric patients including newborns by taking such problems into consideration and carefully coping with them. The present study consisted of 60 pediatric patients treated with CHDF. Clinical efficacy and safety of CHDF in pediatric patients were assessed in these patients by reviewing patient clinical records. The 60 patients treated with CHDF included 27 males and 33 females. Their body weight ranged from 700 g to 53.0 kg. The mean CHDF duration was 6.80 ± 6.94 days. Blood access was provided in a veno-venous mode in 42 patients, and an arterio-venous mode in 18 patients. Of the 60 pediatric patients receiving CHDF, 31 patients survived without serious complications, achieving a survival rate of 51.7%. Successful CHDF in pediatric patients was achieved by careful and exact execution of the following countermeasures to overcome problems specific to application of this therapy to pediatric patients: minimization of the priming volume; use of colloid solutions or whole blood as priming solution; maintaining secure blood access; selection of an appropriate anticoagulant; temperature control of both the patient's body and components of the hemofiltration circuit. In pediatric critical care, CHDF is safely applicable to the critically ill and expected to produce a wide spectrum of clinical efficacy just as in adults.

われわれは劇症肝炎(FH)に対しartificial liver support (ALS)を施行しているが,ALSを含む集中治療のみでは救命できない症例が存在する。当科では日本急性肝不全研究会肝移植適応基準に加え,亜急性型もしくは肝萎縮の認められる症例についても肝移植の適応とみなしている。今回FH症例における生体肝移植に関する問題点を明らかにし,対策を考える目的で,肝移植を実施した症例と移植適応ではあったが実施しなかった症例について検討した。最近5年間に経験した22例のFH症例のうち移植適応と判断されたのは19例で,このうち6例(31.6%)に生体肝移植を実施した。2例は術後重症感染症により死亡したが4例を救命した。当科の移植適応基準におけるpositive predictive value (PPV)は0.79, negative predictive value (NPV)は1.00, sensitivityは1.00, predictive accuracy (PA)は0.81といずれも肝移植適応ガイドラインより良好で,specificityは0.40で同値であった。King's College Hospitalの移植適応基準は,sensitivityが0.09と低い値を示し,わが国のFHの病態に即していないと考えられた。また,与芝の式を用いるとPPV, specificityが良好だったが,NPV, sensitivityは0.56で,すでに劇症化した症例には当てはまらないと考えられた。一方,適応基準を満たしたが移植を実施しなかった14例のうち3例は集中治療によって救命し得たが,11例が死亡した。移植を実施できなかった理由として,重症感染症4例,コントロール不能な出血4例などのrecipient側の因子によるものだけでなく,ドナー不在,家族の反対などの社会的,経済的な因子によるものも5例認めた。以上より,FHに対する生体肝移植の問題点として,移植適応基準,ドナーの確保,移植を行えない症例に対する治療の3点が明らかとなり,移植適応基準の再検討,生体肝移植におけるガイドラインや法律の整備を含めたシステムの構築が必要であると考えられた。

The aim of our study was to examine renal replacement therapies (RRT) that have been used for acute renal failure (ARF) in our intensive care unit (ICU) patients and to compare their outcomes. Sixteen patients who underwent intermittent hemodialysis (IHD), 14 patients who underwent continuous hemofiltration (CHF) in combination with IHD (CHF + IHD), and 38 patients who underwent continuous hemodiafiltration (CHDF) were evaluated. Regarding the effects of blood purification on hemodynamics and renal function, the percentage increase in blood pressure and percent rapid increase in urinary output were the greatest in the CHDF group. The hourly urinary output after the start of initial blood purification increased only in the CHDF group. The survival rate was significantly higher in the CHDF group. These results suggest that CHDF should be the first-line therapy for patients with ARF and that we are moving in the right direction regarding the application of RRT to treat ARF in ICU patients.

目的:重症急性膵炎(severe acute pancreatitis: SAP)症例における重症度判定に際し腹部CT検査は必須であり,われわれは厚生省研究班によるCT grade分類を用いてICU入室時および経過中に撮影した腹部CTのgradingを行っている。また現在当施設ではIL-6 (interleukin-6)血中濃度迅速測定が可能であり,その結果はSAPの重症度の指標として有用であると考えている。そこで今回SAP症例の腹部CT所見とIL-6血中濃度との相関を明らかにする目的で以下の検討を行った。対象:自験SAP症例のうちIL-6血中濃度を測定し得た31例を対象とし,入室時のCT grade, IL-6血中濃度およびAPACHE II scoreを検討した。結果:対象31例の入室時CT gradeの内訳はIII度6例,IV度22例,V度3例であった。grade別の入室時平均IL-6血中濃度は,III度269pg/ml, IV度1,214pg/ml, V度1,578pg/mlであり,同様にgrade別の入室時平均APACHE II scoreは,III度11.67, IV度18.33, V度16.30であった。入室時CT gradeとIL-6血中濃度の相関については,gradeが上がるほど血中濃度も高値になる傾向がみられたが,有意な相関は認めなかった。またCT gradeとAPACHE II scoreについても同様に有意な相関は認めなかった。一方,CT gradeを含む各種予後因子の合計スコアを算出したstage分類によると,入室時stage 2に分類されたのは12症例であり,入室時IL-6血中濃度は平均で393pg/mlであった。同様にstage 3は18例で平均1,539pg/ml, stage 4に分類された症例は1例のみであった。stage 2とstage 3の間ではIL-6血中濃度平均値の有意な差を認めた(p

Continuous hemofiltration and continuous hemodiafiltration (CHF/CHDF) were developed as continuous renal replacement therapy for patients with severe conditons and has come to be widely performed mainly in critical care, taking the place of intermittent hemodialysis. The membrane pore size of a hemofilter used for CHF/CHDF allows passage of substances ranging from 30,000 to 50,000 Da, and the method for solute removal in CHF/CHDF employs the principle of convection, which is advantageous for removing middle- to high-molecular-weight substances. As apheresis therapy to remove pathogenic substances in blood, CHF/CHDF is therefore being investigated for its possible effect on various morbid conditions. It has recently been found that CHF/CHDF removes humoral mediators including cytokines, particularly in severe systemic inflammatory response syndromes such as septic shock and severe acute pancreatitis. CHF/CHDF is thus beginning to be performed for the prevention and treatment of organ dysfunction secondary to septic shock, trauma, or acute pancreatitis. CHF/CHDF is also efficacious as artificial liver support in preventing adverse effects caused by plasma exchange (PE) and for continuous removal of hepatic coma-inducing substances. CHF/CHDF is effective for various morbid conditions not only as renal replacement therapy, but also as apheresis therapy and is expected to be applied more widely in critical care in the future.

It has been accepted widely that excessive humoral mediators play important roles in the pathogenesis of organ failure in patients with severe acute pancreatitis (SAP) and that infection of the pancreas due to bacterial translocation (BT) is the most frequent cause of death in SAP. On the other hand, it has been reported that continuous hemodiafiltration (CHDF) removes humoral mediators on hypercytokinemic patients such as those with systemic inflammatory response syndrome. Furthermore, several clinical studies have demonstrated that selective digestive decontamination (SDD) effectively eliminates aerobic Gram-negative bacteria from the intestinal tract and reduces the incidence of septic complications in SAP. Herein we report a case of SAP who was treated successfully with intensive care including CHDF and SDD. Thus, this case report suggests that CHDF aimed at removing causative humoral mediators and SDD for the prevention of BT are useful new tools for the management of SAP.

われわれはSAPの本態を全身性炎症反応症候群(SIRS)の重症化であるとの考えから,SIRS対策としてのCHDFを中心とする集中治療を施行してきた。SIRSの本態は高cytokine血症であり,なかでもIL-6は侵襲に対する早期反応の重要なmediatorのひとつとされている。最近IL-6血中濃度迅速測定システムを導入することにより,30分程度で測定し患者の重症度を評価できるようになった。今回本システムを用いて,SAP症例のIL-6血中濃度を経時的に測定することにより,CHDFの適応を決定し本システムの有用性につき検討した。対象はSAP症例8例(男性5例,女性3例,年齢57.4±12.7歳,平均±標準偏差)であり,それら対象における臨床経過,転帰,化学発光酵素免疫測定(CLEIA)システムを用いて迅速測定したIL-6血中濃度の推移等につき検討した。さらに本システム導入以前のICU経過中,腎不全非合併SAP症例6例と今回対象中の腎不全非合併例7例とをCHDF施行期間につき比較検討した。全8例が厚生省重症急性膵炎診断基準を満たし,かつわれわれが以前の検討で示したSAPによる臓器不全発症のcritical levelであるIL-6血中濃度400pg/mlに全例がほぼ達していた(393～7140pg/ml)ため入室後直ちにCHDFを開始した。入室時1760±2430pg/mlであったIL-6血中濃度は,SAPの病態改善に伴ってCHDF開始前に比し有意に低下し(p

To compare the effects of intravenous immunoglobulin (IVIg) therapy and plasmapheresis for the IgG anti-GM1-positive subtype of Guillain-Barre syndrome (GBS), clinical and electrophysiological recoveries were analyzed in 24 patients treated with IVIg (n = 10) or plasmapheresis (n = 14). At entry, there were no significant differences between the two patient groups in age, sex, clinical severity (Hughes grade), sum scores of distally evoked amplitudes of compound muscle action potentials (CMAPs), and frequency of Campylobacter jejuni infection. The patients treated with IVIg had significantly lower Hughes grade scores 1, 3, and 6 months after onset (P = 0.03), and a higher probability to regain independent locomotion at 6 months [P(logrank) = 0.044]. In the IVIg group, markedly rapid recovery (improvement by two or more Hughes grade scores within 4 weeks) was more frequent (6 of 10 vs. 3 of 14, P = 0. 03), and delayed recovery (unable to walk independently at 6 months) was less frequent (0 of 10 vs. 4 of 14, P = 0.06). CMAP sum score at 6 months tended to be greater for the IVIg group (P = 0.07). For the IgG anti-GM1-positive subgroup of GBS patients, IVIg therapy may be a more efficacious treatment than plasmapheresis.

Toxic epidermal necrolysis is a life-threatening skin disorder, and its mortality rate is estimated to be approximately 20-30%. It is characterized that more than 30% of the skin surface is eroded, however, skin lesions are usually re-epithelialized within 2-3 weeks. Previously, we reported a fatal case of toxic epidermal necrolysis with hyperbilirubinemia, and more than 60% of body surface areas had been eroded for 9 weeks. For the reason of delayed re-epithelialization, we hypothesized that hyperbilirubinemia was the culprit because bilirubin damaged cultured keratinocytes in vitro. In this case, we had an opportunity to treat another case of toxic epidermal necrolysis with severe hyperbilirubinemia. In order to reduce serum bilirubin levels, we performed bilirubin adsorption therapies, and skin lesions were successfully re-epithelialized within 4 weeks. Though further studies are required, we considered that bilirubin adsorption therapies are worth trying for toxic epidermal necrolysis with hyperbilirubinemia, especially for the cases suffering from delayed re-epithelialization.

血漿交換(PE)は人工肝補助療法(ALS)として,劇症肝炎(FH)の救命率の向上に大きな役割を果たしてきた。しかしFHに対するPEは健康保険上,一連につきおおむね7回を限度とするとして施行回数を制限されており,臨床の現場における治療方針に影響を与えている。今回PEの施行回数に対する保険上の制約が適切であるかどうかについてICUに入室したFH 46例の治療成績を用いて検討した。(1)救命数は14例,救命率は30.4%であった。急性型の救命率は50%,亜急性型は12.5%であり有意に急性型の方が高かった(p

目的:種々の侵襲に対する過剰な生体反応が組織酸素代謝の失調を来し,細胞障害に続いてさまざまな臓器に障害を引き起こすことが知られている。そこでわれわれは胃粘膜内pH (gastric intramucosal pH,以下gastric pHiと略す)を測定,既存の指標と比較し,重症患者における組織酸素代謝について検討を加え,その失調に対する対策についても若干の検討を加えた。対象と方法:対象は1992年9月より1994年9月までに当救急部ICUに入室した症例の38例である。gastric pHiの他に,酸素供給量係数(以下DOIと略す),酸素消費量係数,血中lactate濃度,動脈血中ケトン体比,osmolality gap, cellular injury score(以下CISと略す)を測定し比較検討した。結果と考察:gastric pHiはlactate, CISと有意の負の相関を示し,組織での酸素の需給バランスがくずれoxygen debtが存在した場合lactate上昇とともにpHiも低下し,続いて細胞障害が発生している可能性が示唆された。一方gastric pHiはDOIが高値を示す領域では有意の負の相関を示した。その理由として以下の二点が考えられた。すなわち第一点としてhyperdynamic stateであるほど細胞のoxygen demandもより増大しているため,それを満たすだけのoxygen uptakeがhumoral mediatorなどのために不可能となっているのではないかということと,第二点として既に不可逆的な細胞障害を生じているためではないかということである。以上より組織酸素代謝の状態を評価するためにはDOIの測定のみならず,組織でのoxygen debtの有無とその結果としての細胞障害の有無を監視することが重要である。gastric pHiは細胞でのoxygen debtを表す指標として有用で,経時的に測定することで組織酸素代謝の変化を早期に発見することが可能となることが示唆された。また組織酸素代謝失調の治療にあたっては,治療効果を判定する指標および最終目標としてgastric pHiは適切であると考えられた。

目的:肝細胞ミトコンドリア機能を表し,肝のエネルギー代謝動態を示す動脈血中ケトン体比(arterial ketone body ratio,以下AKBRと略す)は,肝移植や肝切除等の肝臓外科,救急・集中治療領域において,肝障害の重症度を知る指標として広く用いられている。本研究は,劇症肝炎の診断基準および肝機能評価法としてのAKBRおよびケトン体量の有用性と問題点について検討することを目的とした。対象および方法:1987.9～1992.9の間に当施設において治療した劇症肝炎26例(急性型14例,亜急性型12例)を対象とした。ICU入室から退室までの間,連日動脈採血し,acetoacetate (ACAC), β-hydroxybutyrate (BOHB)を測定し,AKBR (ACAC/BOHB),ケトン体量(ACAC+BOHB)を算出した。結果:ICU入室時の急性型,亜急性型のAKBRは,それぞれ0.39±0.22, 0.94±0.31で急性型が有意に低値であった(p