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The Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) system aggregates information related to antimicrobial resistance (AMR) measures in participating medical institutions nationwide and is intended to be used for promotion of AMR measures in participating facilities and their communities. This multicenter study aimed to determine the usefulness of the J-SIPHE system for evaluating the correlation between antibiotic use and antibiotic resistance in Hokkaido, Japan.Data on antibiotic use and detection rate of major resistant Gram-negative bacteria at 19 hospitals in 2020 were collected from the J-SIPHE system, and data correlations were analyzed using JMP Pro.The detection rate of carbapenem-resistant Pseudomonas aeruginosa was significantly positively correlated with carbapenem use (Spearman's ρ = 0.551; P = .015). There were significant positive correlations between the detection rate of fluoroquinolone-resistant Escherichia coli and the use of piperacillin/tazobactam, carbapenems, and quinolones [ρ = 0.518 (P = .023), ρ = 0.76 (P.001), and ρ = 0.502 (P = .029), respectively].This is the first multicenter study to investigate the correlation between antibiotic use and antibiotic resistance using the J-SIPHE system. The results suggest that using this system may be beneficial for promoting AMR measures.

BACKGROUND We investigated whether patients with out-of-hospital cardiac arrest (OHCA) and sustained ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT) or conversion to pulseless electrical activity/asystole (PEA/asystole) benefit more from extracorporeal cardiopulmonary resuscitation (ECPR). Methods and Results: We analyzed data from the Study of Advanced Life Support for Ventricular Fibrillation with Extracorporeal Circulation in Japan, which was a prospective, multicenter, observational study with 22 institutions in the ECPR group and 17 institutions in the conventional CPR (CCPR) group. Patients were divided into 4 groups by cardiac rhythm and CPR group. The primary endpoint was favorable neurological outcome, defined as Cerebral Performance Category 1 or 2 at 6 months. A total of 407 patients had refractory OHCA with VF/pVT on initial electrocardiogram. The proportion of ECPR patients with favorable neurological outcome was significantly higher in the sustained VF/pVT group than in the conversion to PEA/asystole group (20%, 25/126 vs. 3%, 4/122, P

Aim Extracorporeal cardiopulmonary resuscitation (ECPR) is an evolving resuscitative method for refractory cardiopulmonary arrests. However, considering the substantial healthcare costs and resources involved, there is an urgent need for a full economic evaluation. We therefore assessed the cost-effectiveness of ECPR for refractory ventricular fibrillation/pulseless ventricular tachycardia (VF/pVT). Methods We developed a decision model to estimate lifetime costs and outcomes for out-of-hospital cardiac arrest patients with VF/pVT who received either ECPR or conventional cardiopulmonary resuscitation. Quality-adjusted life-years (QALY) was used as the main outcome measure. This model was a combination of a decision tree model for the acute phase based on a prospective observational study (SAVE-J study), together with a Markov model for long-term follow-up periods extrapolated from published data. To evaluate the robustness of this model, we conducted a comprehensive deterministic sensitivity analysis (DSA) and a probabilistic sensitivity analysis (PSA). Results ECPR was cost-effective, with an incremental cost of ¥3,521,189 (Є30,227), an incremental effectiveness of 1.34 QALY, and an incremental cost-effectiveness ratio of ¥2,619,692 (Є22,489) per QALY gained. DSA revealed that the present model was most sensitive to probability of Cerebral Performance Category 1 after ECPR (¥2,153,977/QALY to ¥3,186,475/QALY), patient age (¥2,170,112/QALY to ¥3,334,252/QALY), and long-term medical cost for modified Rankin Scale 0 (¥2,280,352/QALY to ¥2,855,330/QALY). PSA indicated ECPR to be cost-effective and below the willingness-to-pay threshold of ¥5,000,000 with an 86.7 % possibility. Conclusions ECPR was an economically acceptable resuscitative strategy, and the results of the present study were robust even when considering the uncertainty of all parameters.

Hyperbaric oxygen (HBO) therapy was first introduced to Japan around 1963 for cardiac surgery (Wada and Iwa, Proceedings of the fourth international congress on hyperbaric medicine, Igaku Shoin, Tokyo, 1–549, 1970). But now this therapy is especially carried out in brain surgery hospitals because high medical insurance mark is recognized for stroke in Japan. However, the evidence to stroke is not established until now. The large clinical control studies should be needed to establish evidence-based medicine.

Background Visceral injury is a life-threatening complication of cardiopulmonary resuscitation (CPR); however, the clinical significance has been masked by the lethal outcome of out-of-hospital cardiac arrest (OHCA). Objective The objective is to share our experience of successful treatment of OHCA patients with serious, CPR-related visceral complications. Case Reports We report two cases of cardiac-origin OHCA with liver injury exacerbated by heparinization during mechanical circulatory support. Although both patients presented with delayed massive liver bleeding (intrahepatic or peritoneal) that compromised hemodynamic status, one patient was successfully treated by selective transcatheter arterial embolization and the other by a surgical procedure. Conclusion Preventive measures such as careful CPR, as well as interventional or surgical repair after the early diagnosis of visceral injury, are required to improve the outcome in some cases of OHCA.

Percutaneous catheter drainage (PCD) has been considered a standard method of relieving acute cardiac tamponade. Although conventional subxiphoid pericardiotomy is useful even for clotted hemopericardium, it has been believed to be unsuitable for emergency treatment because it is a time-consuming procedure. We report our modified pericardiotomy technique that can be used for emergency management. We designed a prospective observational study to evaluate blind subxiphoid pericardiotomy (BSP) for critical cardiac tamponade due to hemopericardium. Emergency patients (n = 148) with acute hemopericardium secondary to trauma (n = 12), acute aortic disease (n = 122), or cardiac rupture following acute myocardial infarction (n = 14) were the subjects. Early results were compared between the BSP group (n = 53) and the PCD group (n = 95). BSP was effective at relieving cardiac tamponade in all 53 cases, but PCD was ineffective in 12 cases (12.6 %, p = 0.008). Procedure-related complication rates of BSP and PCD were 0 and 16.8 %, respectively (p = 0.002). Survival rates for the BSP and PCD groups were 18.9 and 6.3 %, respectively (p = 0.018). Since 2005, when we discarded the restriction that only board-certified surgeons should perform BSP, acute care physicians (including trainees) have performed BSP for 22 patients without procedure-related complications. BSP was safe and effective for cardiac tamponade due to acute hemopericardium. Critical complications during PCD for hemopericardium could not be avoided in some cases because of clots in the pericardium.

Purpose: We report our experience of Video-assisted thoracic surgery (VATS) to treat acute blunt traumatic hemothorax using mini-thoracotomy. Methods: We designed a prospective study to determine if VATS with mini-thoracotomy benefits for patients with blunt traumatic hemothorax compared with conventional repair through full thoracotomy. Twenty-five patients underwent emergency operation for acute hemothorax from 2000. Five patients with less than 5% probability of survival (PS) were excluded, leaving 20 as the subjects. Results: Ten patients underwent conventional thoracotomy (conventional group) and the other 10 patients underwent VATS with mini-thoracotomy (VATS group). There was no difference between conventional group and VATS group in injury severity score (29.1 and 27.0) or PS (81.2% and 80.7%). Hospital mortality rates were 10% in conventional group and 0% in VATS group (N.S). Total amounts of intra-operative bleeding and post-operative transfusion until day 7 were 735 ml and 19.3 units in conventional group and 303 ml and 9.2 units in VATS group respectively (N.S). The length of ICU stay was 9.7 days in conventional group and 5.9 days in VATS group (N.S). Conclusion: VATS with mini-thoracotomy can be alternative for patients with blunt traumatic hemothorax in most emergency operations.

Objective The aim of this study is to describe the effect emergency cardiopulmonary bypass (CPB) for resuscitation on the survival rate of patients. Methods The study population was composed of persons 16 years or older who had out-of-hospital cardiac arrest and were transferred to the Sapporo Medical University Hospital from the scene between January 1, 2000, and September 30, 2004. Children younger than 16 years and persons who were dead were excluded. Data were collected according to the Utstein style. Survival rates and cerebral performance category were analyzed using χ 2 analysis for the patients with presumed cardiac etiology. Cardiopulmonary bypass was applied to patients who showed no response with standard advanced cardiac life support. The interval from collapse and other noncardiac etiologies were considered criteria for exclusion. Results Of the 919 patient medical records reviewed, CPB was performed in 92 patients. Of the 919 patients, 398 were of presumed cardiac etiology (n = 66 for CPB), 48 patients survived, and 24 patients (n = 7 for CPB) had a good cerebral outcome (cerebral performance category score 1). With CPB, the rate of survival at 3 months increased significantly (22.7% vs 9.9%, P P = .087) showed a positive trend. Conclusion The use of CPB for arrest patients was associated with reduced mortality. It did not increase good neurologic outcome significantly. Still, 7 cases with intact central nervous system would have been lost without CPB.

Background Although the left subclavian artery (LSA) is simply covered to exclude distal aortic arch aneurysm during endovascular stent-grafting, this technique is potentially harmful. Methods and Results Between January 2001 and April 2005, 40 cases of stent-grafting were performed for distal aortic arch diseases. For all 31 elective cases, the LSA occlusion test using a balloon catheter was preoperatively performed to predict critical complications secondary to LSA coverage by a stent graft and this revealed 2 cases in which the LSA was crucial for brain circulation (6.5%). The LSA was saved by using a hand-made fenestrated stent graft without bypass-grafting to the LSA in 22 cases. Bypass-grafting to LSA was performed in 5 cases. The LSA was simply occluded in 13 cases. Hospital mortality rates for the elective and emergency cases were 3.2% and 30.0%, respectively. One elective patient had a cerebral infarction (2.5%). LSA patency was successfully maintained in all 22 cases using a fenestrated stent graft. Conclusion The LSA plays an important role in brain circulation in some patients and so a preoperative LSA occlusion test is helpful when aortic stent-grafting is proposed. Fenestrated stent graft saved the LSA in more than 50% of the present cases. (Circ J 2008; 72: 449 - 453)

Les patients presentant une ischemie de jambe secondaire a une dissection aortique aigue sont generalement traites par pontage extra-anatomique. Cependant, ces patients sont egalement a haut risque de complications arterielles viscerales. Nous presentons un cas d'ischemie de jambe secondaire a une dissection aortique aigue, qui a pu etre traite d'emblee par stent-graft. Un homme de 58 ans etait transfere dans notre hopital pour une ischemie aigue de jambe droite. Le scanner montrait un infarctus partiel du rein droit et une compression importante du vrai chenal au niveau de l'aorte abdominale. La mise en place d'un stent-graft en urgence plutot que la realisation d'un pontage extra-anatomique pour traiter l'ischemie de jambe a ete choisie pour prendre en compte la possibilite de complications vasculaires viscerales. Le pouls femoral droit etait immediatement percu apres le largage du stent-graft. La fermeture primaire de la porte d'entree par un stent-graft pourrait etre un traitement de choix des complications des dissections aortiques aigues.

OBJECT In patients with severe traumatic brain injury (TBI), a randomized controlled trial revealed that outcomes did not significantly improve after therapeutic hypothermia (TH) or normothermia (TN). However, avoiding pyrexia, which is often associated with intracranial disorders, might improve clinical outcomes. The objective of this study was to compare neurological outcomes among patients with moderate and severe TBI after therapeutic temperature modulation (TTM) in the absence of other interventions. METHODS Data from 1091 patients were obtained from the Japan Neurotrauma Data Bank Project 2009, a cohort observational study. Patients with cardiac arrest, those with a Glasgow Coma Scale score of 3 and dilated fixed pupils, and those whose cause of death was injury to another area of the body were excluded, leaving 687 patients aged 16 years or older in this study. The patients were divided into 2 groups: the TTM group underwent TN (213 patients) or TH (82 patients), and the control group (392 patients) did not receive TTM. The primary end point for this study was the rate of poor outcome at hospital discharge, and the secondary end point was in-hospital death. Out of the 208 total items in the database, 29 variables that could potentially affect outcome were matched using the propensity score (PS) method in order to reduce selection bias and balance the baseline characteristics. RESULTS From each group, 141 patients were extracted using the PS-matching process. Among the patients in the TTM group, 29 had undergone TH and 112 had undergone TN. In a log-rank test using Kaplan-Meier survival curves, no significant differences in patient outcome or death were observed between the 2 groups (poor outcome, p = 0.83; death, p = 0.18). A Cox proportional-hazards regression analysis established the HR for poor outcome and mortality at 1.03 (95% CI 0.78–1.36, p = 0.83) and 1.34 (95% CI 0.87–2.07, p = 0.18), respectively. CONCLUSIONS There was no clear improvement in neurological outcomes after TTM in patients with moderate or severe TBI. To elucidate the role of TTM in patients with these injuries, a prospective study is needed with long-term follow-up using specific target temperatures.

厳密な血糖コントロールは重症患者の予後を改善させると言われているが,頻回の血糖測定が必要で,実際の施行には障害が大きい。今回,経静脈的持続血糖測定器を使用する機会を得たので,精度を動脈血血糖値と比較検討し,さらに施行上の問題点について報告する。【対象と方法】当院集中治療室入院中に同意を得た6例のうち,静脈内に20ゲージ専用留置針を留置できた2例に,人工膵臓STG(R)-22(日機装,東京)に接続して血糖値を持続モニターし,動脈血血液ガス分析装置の血糖値と比較検討した。【結果】動脈血と静脈血,血糖値の間にはr=0.964と非常に高い相関関係が得られた。Bland-Altman plotでは,負の相関関係がみられた。【考察および問題点】血糖値が高くなるにつれ,STG(R)-22による静脈血血糖値が動脈血血糖値に比べて低値となったが,これは機械的な性能ではなく,血糖値の増加に従い,動静脈血較差が広がるためと考えられた。また,ICUのベッドサイドにおける使用に際しては機器が大きい,回路が長くできないといった問題があり,今後,さらなる改良の必要性が示唆された。

胸腹部大動脈瘤(thoraco-abdominal aortic aneurysm, TAAA)術後の腸管虚血の診断に血清乳酸値が有用であった症例を経験した。症例は73歳,女性。胸腹部大動脈瘤の診断にてステント挿入術と,腹部分枝に対する人工血管を用いたバイパス術を施行した。術中およびICU入室後,低酸素血症やショックに陥ることがなかったが,腹部分枝バイパス終了6時間後から血清乳酸値の上昇と代謝性アシドーシスが進行した。代謝の亢進や肝不全,循環不全,呼吸不全を示唆する所見がなかったため,腸管虚血を疑った。試験開腹術を行ったところ,上腸間膜動脈にバイパスしたグラフトが屈曲し,血流が遮断されていた。直ちに虚血を解除し,新たにバイパス術を追加した。ICU帰室後,血清乳酸値は4時間で正常化し,患者は合併症を併発せず,第5病日には一般病棟へ退室した。大動脈疾患に伴う腸管虚血の診断は臨床症状以外では困難な場合が多い。血清乳酸値の特性を十分に把握した上での連続モニタリングは,大動脈疾患に伴う腸管虚血の診断に有用な補助手段となることが示唆された。

A 38-year-old man presented with a dysplastic cerebellar gangliocytoma associated with a paraspinal arteriovenous fistula (AVF) at the upper cervical portion. Neuroimaging examination indicated the diagnosis of Lhermitte-Duclos disease. The patient was treated by embolization of the AVF followed by partial resection of the cerebellar tumor. Genetic examination showed a mutation of the phosphatase and tensin homolog deleted on chromosome ten (PTEN) gene. Histological examination confirmed the diagnosis. Lhermitte-Duclos disease is a rare dysplastic gangliocytoma manifesting as a slowly growing mass in the cerebellum and is usually asymptomatic. This case of Lhermitte-Duclos disease associated with paraspinal AVF and mutation of the PTEN gene suggests a relationship between Lhermitte-Duclos disease and Cowden disease.

心肺蘇生法としての胸骨圧迫心マッサージは,脳蘇生の観点からその効果に限界があることが指摘され,新たな心肺脳蘇生法として人工心肺の可能性が注目された。しかし,救急領域での臨床応用のためには,現在のPCPSシステムを構成しているような膜型人工肺や遠心ポンプ,経皮的挿入可能な送脱血カニューレ等の開発といった医療工学の発達を待たなければならなかった。心停止症例への本格的な臨床応用としては,1983年にPhillipsらが5例中3例を救命したことを報告し,1989年からはSaferらによって臨床研究が開始され,1992年に187例中40例(21%)生存という極めて良好な結果が報告されている。当施設では1988年から院外心停止症例に対して蘇生法としてPCPSを2005年3月までに156例に対して施行し,救命例が34例(21.2%)で16例(10.2%)の社会復帰症例を得ている。病院前救護体制の向上,心原性疾患に対する根本的治療体制整備,蘚生後の後療法である脳低温療法の導入等,われわれが“院外心肺停止症例に対するPCPSを組込んだ包括的な救命医療”と呼んでいる概念を意識しはじめた1999年以降は,PCPS導入時間の明らかな短縮と救命症例の増加が認められている。心肺脳蘇生法としてのPCPSの問題点としては,明確な適応基準が無くその評価自体も未だに定まっていないことが挙げられる。しかしながら,通常の二次救命処置が無効であった症例に1999年以降は10%以上の社会復帰例が存在することは無視できないと考えられる。そこで今後は,これまで症例を検討し新しい適応基準を作成し,前向きな検討を考慮している。また,PCPSは高コスト治療であると指摘されるが,院外心停止症例に対しては,その救命のためにすでに様々形でコストがかかっていることを考慮すべきである。

Guillain-Barre症候群(GBS)は,先行感染に遅れて1-3週間後に四肢の筋力低下,深部腱反射の消失などの症状が出現するが,先行感染による急性炎症反応亢進は軽度であることが多い。一方,critical illness polyneuropathy (CIP)は敗血症,多臓器不全,呼吸不全,SIRSからの回復期に,人工呼吸器からの離脱困難,四肢の筋力低下,腱反射の消失の症状を呈する。重複する感染症の程度によって,両者の鑑別は比較的容易であると考えられる。今回,先行感染があったが,敗血症性ショックからの回復期に四肢の運動障害,意識障害を呈し,CIPとの鑑別に苦慮した軸索型GBSの一例を経験したので報告する。症例は64歳の男性で,2週間前より発熱がみられ,内服薬が処方されていたが,症状の改善がみられず重症肺炎と急性腎不全を合併したため,当院へ緊急搬送された。敗血症性ショックを合併し,抗生物質,人工呼吸管理と持続血液濾過透析などの治療を行った。入院9日目より酸素化能の改善がみられ,ショックから離脱したが,人工呼吸器の圧補助を下げることができなかった。そこでGBSを疑ったが,髄液検査ではタンパク細胞解離はなかった。末梢神経伝導速度では運動神経の軸索型障害がみられた。後日判明した入院4日目のマイコプラズマ抗体価は2560倍であったため,マイコプラズマ肺炎による運動神経障害(acute motor axonal neuropathy; AMAN)型GBSと診断した。CIPは敗血症などの重症急性疾患の治療中に発症し,全身状態の改善とともに症状が改善する。しかし,GBSでは神経障害の回復には血漿交換や大量ガンマグロブリン投与が確立しており,本症例のように敗血症治療後に人工呼吸器からの離脱困難や四肢筋力の低下などのCIPを疑う症状がみられた場合には電気生理学的検査などを行い,GBSを除外する必要があると考えられる。

経皮二酸化炭素分圧(PtcCO2)測定とパルスオキシメータの小型センサーを同時に搭載した耳朶センサーを用いた測定装置TOSCA(R)(Linde社,スイス)の集中治療室での使用経験を報告した。対象はICUに入室した12症例の重症患者とし,左右いずれかの耳朶にセンサーを装着し,PtcCO2およびSpO2を測定した。適宜動脈血ガス分析を行い,PaCO2とPtcCO2とを比較検討したところ,相関係数0.95と良好な相関関係が得られたが,PaCO2が50mmHg以上ではPtcCO2がPaCO2よりも高くなり解離していく傾向があった。測定に伴う重篤な合併症はなく,体位変換に伴う体動でも測定が可能であった。ノルエピネフリン投与後PtCO2とPaCO2とが解離する症例があった。TOSCA(R)を用いたPtcCO2は,実測値と比べ若干高値に表示されるものの追従性も良く有用と考えられるが,重症患者における低灌流状態でのSpO2を含めた検討がさらに必要である。

Background Little is known about the long-term outcome of implantable cardioverter defibrillator (ICD) therapy in survivors of out-of-hospital cardiac arrest (OHCA). Methods and Results The frequency of lethal ventricular arrhythmias and whether ICD implantation can prevent recurrence of cardiac arrest were examined. Long-term (24.4±11.9 months) outcome was examined in 23 patients with OHCA who were treated with an ICD (OHCA group) and 35 patients without OHCA (non-OHCA group) who were treated with an ICD. Patients in both groups had same clinical backgrounds; however, those in the OHCA group showed a significantly lower incidence of induced ventricular arrhythmias (71%) than the non-OHCA group (96%). In the follow-up period, patients in the OHCA group had almost the same incidence of ICD discharge (30%) as patients in the non-OHCA group (40%). The rate of recurrence of ventricular fibrillation in the OHCA patients was 13%, and it was difficult to estimate the rate by induced ventricular arrhythmia. Conclusion The results suggest that ICD implantation for survivors of OHCA with favorable neurological recovery might be effective for preventing recurrence of cardiac arrest. (Circ J 2006; 70: 1128 - 1132)

Neuronal cell injury after global cerebral ischemic insult is not well understood in humans. We performed serial examination of diffusion-weighted imaging and magnetic resonance spectroscopy in three patients after cardiopulmonary resuscitation. The presence of the signal for lactate in magnetic resonance spectroscopy in the acute stage after cardiopulmonary resuscitation was closely correlated to irreversible damage. In addition, high intensity in diffusion-weighted magnetic resonance image in the acute stage also predicted a poor outcome. Lesions that were positive for these factors in the acute stage led to serious brain damage in the subacute and chronic stages. The results indicated that after cardiopulmonary resuscitation, diffusion-weighted magnetic resonance imaging and magnetic resonance spectroscopy is an extremely useful modality to estimate the prognosis of patients, which is not always easy using conventional methods.

消化管穿孔による後腹膜膿瘍が,大腿輪を経て左側腹部から下腿に波及したために生じた壊死性筋膜炎のまれな1例を経験した。症例は65歳の女性。左側腹部から大腿部にかけての疼痛と皮膚壊死を認めたため壊死性筋膜炎を疑い,当院高度救命救急センターに搬入された。搬入時,呼吸,循環動態は安定していたが,左躯幹から大腿部,外陰部の浮腫,紫斑,硬結,皮膚壊死を認めた。搬入後直ちに,躯幹から下肢にかけての皮膚の壊死部分を筋膜上までdebridementし人工真皮にて被覆した。術中,左鼠径靭帯下部に便の付着と後腹膜方向の交通部があった。開腹したところ結腸脾湾曲部の後腹膜腔への穿孔があり,後腹膜腔には膿瘍が充満した状態であったため,結腸左半切除を行った。穿孔部結腸の病理組織検査では憩室や悪性所見はなかった。術中,術後にわたりショック状態や臓器不全に陥ることなく順調に経過し,第5, 10病日に人工真皮による被覆を行い,さらに第20病日と32病日には,autograftによる植皮術を施行し欠損部を被覆した。下肢壊死性筋膜炎の原因として後腹膜腔への腸管穿孔は非常にまれであるが,原因の一つとして常に可能性を念頭に置く必要がある。本症例では早期かつ広範に壊死した皮膚や皮下組織,筋膜を徹底的にdebridementし,その原因となった腸管に対して処置し得たことが,その後の敗血症の発症や,臓器障害への進展を防止できたと考えられた。

Background Early defibrillation and cardiopulmonary bypass have been postulated to be a promising intervention against out-of-hospital cardiac arrest (OHCA); however, little is known about the long-term prognosis. The effects of early recovery of circulation (ROC) on neurological recovery and the long-term outcome in patients with OHCA were examined. Methods and Results Functional recovery and long-term (22.0±15.3 months) outcome were examined in 100 patients with definite diagnosis of OHCA. Spontaneous circulation recovered in 79% of the patients (using on-site counter shock in 20% of the patients). Cardiopulmonary bypass was performed in 38 of the OHCA patients. The total survival and favorable neurological recovery rates were 40% and 25%, respectively. The patients with favorable recovery obtained early ROC (28.2±16.0 min). Receiver-operating characteristic analysis showed that a period of less than 35 min for ROC was the optimal period for achieving a favorable recovery, with sensitivity of 68% and specificity of 73%. The patients with a prior history of heart failure or reduced left ventricular ejection fraction exhibited more frequent, exacerbated heart failure and ventricular arrhythmias. Conclusions Early ROC using on-site counter shock or cardiopulmonary bypass might result in better long-term outcome in patients with OHCA of cardiac origin. (Circ J 2005; 69: 1302 - 1307)

Background In spite of recent improvements in treatment for acute aortic dissection, mesenteric ischemia secondary to aortic dissection is still challenging. We propose a simple screening method to detect mesenteric ischemia secondary to acute aortic dissection. Methods From 1991 to 2002, 245 patients with acute aortic dissection were admitted to our hospital. Nine (3.7%) of those were complicated with mesenteric ischemia. The clinical records of those 9 patients were retrospectively analyzed. The ratios of the diameter of the superior mesenteric vein (SMV) to that of the superior mesenteric artery (SMA) were calculated in patients with mesenteric ischemia (group M) and in patients without mesenteric ischemia (group C). Blood test data, including results of arterial blood gas analysis, in the 2 groups were also compared. Results The SMV/SMA ratios in groups M and C were 1.16 ± 0.33 and 1.78 ± 0.29, respectively ( P = .003). A cutoff value of the SMV/SMA ratio was 1.5 (sensitivity, 88.9%; specificity, 88.9%) with an odds ratio of 64.0. Although there were differences between the 2 groups in glutamate oxaloacetate transaminase, lactate dehydrogenase, creatine phosphate kinase, pH, and lactate values, the measurement of lactate was especially useful ( P = .002). Conclusions The combination of the SMV/SMA ratio and lactate concentration is a useful screening method to detect mesenteric ischemia secondary to acute aortic dissection.

高エネルギー損傷の結果として生じる治療困難な重度下腿開放骨折(Gustilo type III B, C)に対する皮弁形成術の有用性について検討した。対象症例は2000年4月から2003年10月までの期間において,当救命救急センターにて加療を行った重度下腿開放骨折9例である。男性8例,女性1例で,受傷時平均年齢は32.9歳であった。以上の症例に対して受傷時に積極的デブリドマンと一時的創外固定術を施行し,さらに可能な限り受傷後数日以内に皮弁形成術による軟部組織再建術と確定的骨接合術を施行した。その結果,9例中7例において患肢温存が得られたが,2例は後日切断術を施行した。患肢温存が得られた7例のうち6例は1次骨癒合が獲得され,平均骨癒合期間は5.5か月(3～7か月)であった。骨癒合が遅延した1例に対しては追加骨移植術によって骨癒合が得られた。合併症として骨髄炎を併発した症例は認められなかった。2cm程度の脚短縮が1例に認められたが,10度以上の角状変形と回旋変形を認めた症例はなかった。さらに膝関節可動域および足関節可動域は比較的良好に保たれ,全例受傷1年以内に杖なし歩行が可能となった。重度開放骨折に対する早期皮弁術は非常に有効な手術手技である。

Rhabdomyolysis in four children was evaluated by bone scintigraphy using 99mTecnetium-methyldiphosphate (99mTc-MDP). The ages of the patients ranged from 7 to 14 years old. The causes of rhabdomyolysis were toxic shock syndrome in one patient, excessive exercise in one patient and cardiopulmonary arrest after cardiac surgery and after drowning in two patients. Peak serum creatine kinase (CK) and myoglobin (Mb) levels ranged from 5, 093 to 91, 150IU/l and 7, 486 to 111, 900ng/ml, respectively. Peak serum CK and Mb levels reached during the period from the first to third ICU day. Renal impairment occurred in the patient with toxic shock syndrome. After treatment with continuous hemodiafiltration, the renal impairment improved. Bone scintigraphy using 99mTc-MDP was performed during the period from the third to fifth ICU day. Abnormal accumulation of radioactivity was found in the two patients in whom rhabdomyolysis had been caused by excessive exercise and cardiopulmonary arrest after drowning. Despite the fact that peak CK raised to 12, 500IU/l in the patient of toxic shock syndrome, abnormal accumulation of radioactivity was not found. It was shown that bone scintigraphy using 99mTc-MDP is available for evaluation of rhabdomyolysis in children as it is in adults. However, in children with rhabdomyolysis, greater elevation of CK may be required to detect abnormal accumulation of radioactivity by bone scintigraphy using 99mTc-MDP compared with that in adults.

Penetrating cardiac injuries commonly occur secondary to gunshot or stab wounds. This is a report an unusual case of a patient who sustained a penetrating cardiac injury due to a nail from a terrorism-related, nail-bomb explosion. Associated problems included pericardial tamponade, penetrating cardiac injuries, acute, traumatic, myocardial infarction, and a penetrating lung injury. Prompt diagnosis and aggressive surgical intervention resulted in full recovery of the patient.

Malignancy and operation for it cause several alterations in immune function that are considered to be concerned with the development of infectious complications. Forty-three patients who underwent curative surgery for gastrointestinal malignancies were entered into this study and were divided into two groups, those with and those without postoperative infection. Changes in the proportion of Th1/Th2 subsets in CD4+ T cells and the expression of human leukocyte antigen (HLA)-DR and CD16a molecules on monocytes were measured by flow cytometry before and after surgery. We performed intracellular cytokine stainings to exactly detect Th1/Th2 subsets. The proportions of interferon-γ-producing CD4+ T (Th1) cells in the preoperative state were almost equal in the two groups, and the proportion decreased on postoperative day (POD) 1 in both groups. On POD 7, the proportion of Th1 cells recovered to the preoperative level in the noninfection group, while the suppression was further reinforced in the infection group (26.8% versus 18.3%, p < 0.005). In contrast, the proportion of interleukin-4-producing CD4+ T (Th2) cells in the infection group (11.3%) was already suppressed in the preoperative state when compared with the noninfection group (17.3%, p < 0.005). Changes in HLA-DR and CD16a expression on monocytes were similar to the changes in the proportion of Th1 cells. These results indicate that the suppression of Th1 cell and monocyte functions during the early phase of the postoperative course was directly related to the occurrence of infectious complications and that several immunological impairments have already occurred in the preoperative state in cancer patients.

市立札幌病院救命救急センターでは1991年から院外心肺停止患者に対し,経皮的心肺補助(以下PCPS)を導入しているが,院内でPCPS導入を決定し準備を開始するシステムでは脳蘇生の時間的限界を超える可能性がある。そこで1995年から運用されているドクターカーと連携し,2000年4月からドクターカー内での薬剤投与や電気的除細動に反応しない心原性院外心肺停止患者に対する治療戦略として,積極的かつ迅速にPCPSを導入するために,ドクターカーからPCPSオーダーを行い院内で準備を開始する“pre-hospital PCPS order”システムを導入した。【対象】PCPSは院外心肺停止患者72症例に導入され,このうち心原性症例は58例であった。“pre-hospital PCPS order”を行った症例(以下pre-hospital order群)は13例であり,院内でPCPS導入決定を行った症例(以下in-hospital order群)は45例であった。この2群におけるPCPS導入時間と予後について検討した。【結果】pre-hospital order群での搬入からPCPS導入までの平均時間は搬入から18.1分で最短8分であり,in-hospital order群の43.7分に比べ有意に短縮された。また転帰はpre-hospital order群で社会復帰5例,全介助2例,死亡7例であり,社会復帰率は38.5%となり,in-hospital order群の13.3%より良好であった。【まとめ】心肺脳蘇生おいて心肺停止からいかに早く安定した脳循環を維持できるかが,その患者の生命機能予後を決定するといっても過言ではない。ドクターカー内で薬物投与と電気的除細動に対する反応を観察し,同時にPCPSのオーダーを行い院内でPCPSの準備を開始する本システムは,迅速に安定した脳循環を得ることのできる最も理に適った心肺脳蘇生の治療戦略と考えられる。

We report a case of an abdominal aortic aneurysm which ruptured into the inferior vena cava indicated by CT and angiography in a patient that had been transferred to our hospital with a diagnosis of acute cardiac failure. The patient was a 73-year-old male who had been examined at another hospital for chest pain, hypotension, vomiting and vertigo and had been admitted to our hospital for examination of acute cardiac failure of unknown cause. A pulsating giant mass was palpable in the abdomen, and a continuous murmur was also audible in the abdomen. The patient showed no anemia or abdominal pain, but CT indicated the possibility of the rupture of an abdominal aortic aneurysm into the inferior vena cava. Emergency surgery was successfully performed following confirmation of the rupture by angiography. The results of this case indicate the need to consider a ruptured abdominal aortic aneurysm as a possible cause of symptoms resembling acute cardiac failure.

背景:本邦における院外心原性心肺停止の生命機能予後に及ぼす経皮的心肺補助(PCPS)を用いた積極的治療の意義は必ずしも明確でない。目的:当施設での治療成績を検討し,PCPSを用いた治療の効果を明らかにすることを目的とした。対象と方法:1999年4月から3年間に当救命救急センター搬入となった心原性心肺停止連続187例(男性128例,女性59例;年齢65.5±16.3, 3-94歳)を調査対象とし,急性期生命転帰および機能障害の程度と,これに影響を及ぼす諸因子について検討した。結果:(1)搬入後の治療はPCPS 20例(11%),大動脈バルーンパンピング(IABP) 19例(10%),緊急冠状動脈造影18例中10例に経皮的冠状動脈インターベンション(PCI)を施行,脳低温療法は20例(11%)に施行した。心原性全体で心拍再開率32%,生存率14%,機能良好9%であった。(2)心拍再開もしくはPCPS装着による臓器血流再開時間は機能良好例では平均30.9分で,死亡例,高度障害残存例に比し有意に短かった。(3)治療にPCPSを必要とした20例と,PCPSを用いずに心拍再開した21例(搬入時pulseless electrical activityと心静止は除外)の入院30日後の“機能良好:高度障害残存:死亡”の割合は,PCPS群35%:15%:50%,非PCPS群38%:19%:43%で両群間に有意差を認めなかった。結語:臓器血流再開までの時間が短い症例では,機能回復は比較的良好であり,発症早期にPCPSを用いる積極的な蘇生治療は有効と考えられた。

OBJECTIVES Advances in the field of cardiopulmonary resuscitation have led to an increasing number of patients initially surviving sudden cardiac arrest. Unfortunately, most of these patients do not recover from the resultant anoxic brain insult. Several animal and human trials have suggested that post-resuscitative brain hypothermia may improve neurologic recovery after cardiopulmonary arrest. Present cooling methods are slow, induce only brain surface cooling, or result in systemic hypothermia. The authors tested the hypothesis that unilateral hypothermic carotid bypass would induce bilateral brain cooling without evoking systemic hypothermia or hemodynamic instability. METHODS Anesthetized, ventilated common swine (n = 6, 24-37 kg) underwent right femoral and carotid artery bypass cannulation. Central and peripheral hemodynamic parameters were recorded every 2 minutes throughout the procedure. Thermodynamic parameters included bilateral frontal lobe, bilateral nasopharyngeal, pulmonary artery, and rectal temperatures. Hypothermic femoral-carotid bypass was accomplished by drawing blood from the right femoral artery, cooling it to 24 degrees C, and returning it to the right carotid artery at a flow rate of 5 mL/kg/min for 30 minutes. RESULTS With initiation of cooling, brain temperatures dropped rapidly from baseline of 37.2 degrees C to 30.6 degrees C (right frontal lobe) and 33.1 degrees C (left frontal lobe) at 30 minutes. Pulmonary artery and rectal temperatures also decreased, but never reached mild hypothermic levels (34 degrees C). There was no significant change in any hemodynamic parameters during brain cooling. CONCLUSIONS Femoral-carotid hypothermic bypass rapidly induced a state of selective brain hypothermia without causing systemic hypothermia or hemodynamic instability.

Introduction:The discussions in this theme provided an opportunity to address the unique hazards facing the Pacific Rim.Methods:Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 3 and Theme 7 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.Results:The main points developed during the presentations and discussion included: (1) communication, (2) coordination, (3) advance planning and risk assessment, and (4) resources and knowledge.Discussion:Action plans were summarized in the following ideas: (1) plan disaster responses including the different types, identification of hazards, focusing training based on experiences, and provision of public education; (2) improve coordination and control; (3) maintain communications, assuming infrastructure breakdown; (4) maximize mitigation through standardized evaluations, the creation of a legal framework, and recognition of advocacy and public participation; and (5) provide resources and knowledge through access to existing therapies, the media, and increasing and decentralizing hospital inventories.Conclusions:The problems in the Asia-Pacific rim are little different from those encountered elsewhere in the world. They should be addressed in common with the rest of the world.

A 33-year-old man with hepatic bleeding was transferred to our hospital. Conventional plain and enhanced spiral computed tomography (CT) with a Siemens Somatom Plus-S scanner (Siemens AG, Erlangen, Germany) revealed a large hepatic hematoma and active extrahepatic bleeding. A unified spiral CT and angiography system (IVR-CT/Angio system; Toshiba Medical Systems, Tokyo, Japan) was employed, and selective catheterization-aided CT arteriography (CTA) showed additional active extrahepatic bleeding. These findings were not detected on conventional spiral CT or angiography. The CTA findings led us to successful transarterial embolization (TAE). After TAE, CT scan revealed that the contrast material injected in the hepatic artery was diffusing into the periportal space. Twenty-four days after TAE, a central bisegmentectomy of the liver was performed. Unfortunately, the cause of the hepatic bleeding was not clear pathologically.

急性A型大動脈解離は救急領域において迅速な診断と初期治療開始を要する疾患のひとつである。最近10年間に当院に搬入され急性A型大動脈解離の診断となった146例を対象として早期および遠隔成績を検討し,教室での初期治療方針を報告する。急性A型大動脈解離は一部の早期血栓閉塞例を除いて外科治療の適応としているが,32例(21.9%)が術前死となった。死亡原因は28例(87.5%)が心タンポナーデであり,搬入時心肺停止例は救命が困難であった。初期生存114例中101例(88.6%)が外科治療の適応となり,99例にエントリー切除を目的とした人工血管置換術を施行した。術前ショック32例では在院死亡13例(40.6%)と不良であったが,非ショック69例では10例(14.5%)であった。全体での在院死亡を含めた手術後5年での生存率は68.5%であった。上行置換群と弓部全置換群で早期成績は同等であり,拡大手術による侵襲の影響は少ないと考えられた。また遠隔成績が同等であることより,上行大動脈にエントリーを認める場合は拡大手術の必要性は少ないと考えられた。広範囲解離例において,術後に下行大動脈偽腔の血栓閉塞が確認された群では偽腔開存群に比して解離関連イベントの発生率が有意に抑制されており,末梢吻合側での偽腔血栓化への工夫が今後の課題と思われた。早期血栓閉塞38例(33.3%)に対して,13例に内科治療を選択したが3例が早期再解離にて死亡した。術前ショック例を除き外科治療を選択した17例に在院死亡を認めなかった。早期血栓閉塞症例に対する内科治療の選択には慎重な態度が必要であろう。

Brachial plexus injury often causes severe chronic upper limb pain that persists for a long time. We present 2 cases in which brachial plexus avulsion pain was managed by epidural block. Brachial plexus avulsion caused by motorbike accidents elicited severe abnormal sensations in the upper limbs, where there was complete loss of motor and sensory neurological functions. There was continuous burning and intermittent cutting pain such as causalgia in the forearm of 1 patient and an oppressive sensation such as extraction of the upper arm from the shoulder in the other patient. Continuous cervical epidural blocks were applied to both patients immediately, resulting in obvious reduction in the degree of acute pain and in the induction of chronic pain in the upper limbs. This suggests that application of cervical epidural block in the early phase is an effective therapy for patients suffering brachial plexus injury for inhibiting the chronic upper limb pain. Note that should notice application of satisfactory analgesia even in emergency cases should be as fast as possible if there is a possibility that trauma will lead to chronic pain.

A case of transfusion-related acute lung injury (TRALI) that was successfully treated with extracorporeal membranous oxygenation (ECMO) is reported. A 58-year-old male patient underwent hepatectomy, and pulmonary edema occurred after the administration of fresh-frozen plasma and packed red cells. In the postoperative period, the impaired oxygenation progressively worsened, resulting in life-threatening hypoxemia, despite vigorous treatments. ECMO was therefore applied to the patient as a method of safe emergency support. Aggressive treatments under ECMO led to the successful improvement of the impaired oxygenation. TRALI is recognized as part of acute respiratory distress syndrome (ARDS). As a treatment for ARDS, ECMO does not cure the underlying disease of the lungs, however, with ECMO, TRALI, usually improves within 96 h with respiratory support. ECMO for TRALI-induced lethal hypoxemia is useful for providing time to allow the injured lung to recover. It is suggested that ECMO might be a useful option for the treatment of TRALI-induced, potentially lethal hypoxemia.

The sensitivity of susceptibility-weighted magnetic resonance (MR) imaging was compared with conventional MR sequences, including T(2)*-weighted imaging, and computed tomography for the detection of cerebral hemorrhages in 15 patients with head injury. Susceptibility-weighted imaging detected a mean of 76+/-52 (total 1132) hypointense spotty lesions, compared to a mean of 21+/-19 (total 316) detected by T(2)*-weighted imaging (p0.0001, paired t-test). Susceptibility-weighted imaging is extremely sensitive for the visualization and detection of microhemorrhages.

Penetrating cardiac injury tends to generally be repaired without cardiopulmonary bypass in the operating room. We herein report the case of penetrating cardiac injury repaired using percutaneous cardiopulmonary support in an emergency room. A 57-year-old man attempted suicide by stabbing himself in the left anterior chest with a knife. Although the patient suffered cardiopulmonary arrest for 7 min in the ambulance, spontaneous circulation was restored following pericardiotomy through emergency left thoracotomy in the emergency room. To prevent coronary artery injury and control the massive bleeding, percutaneous cardiopulmonary support was instituted without systemic heparinization and the cardiac injury was repaired in the emergency room. The patient was then transferred to another hospital on day 46 for further rehabilitation. Percutaneous cardiopulmonary support might be helpful for treating critical patients in an emergency room, even in the case of trauma patients.

Alveolar soft part sarcoma (ASPS) is a rare soft tissue neoplasm. The coexistence of ASPS with cardiac metastasis is quite rare, in particular. In general, the sarcoma is a malignant disease and grows very fast. However, the mean survival time of patients with ASPS is relatively long. Patients who are diagnosed with localized disease usually have a favorable prognosis, while those who present with widespread metastases usually have a poor prognosis and ultimately, succumb to their disease. The use of modern treatment modalities, such as combination of surgery, and radiotherapy, may significantly prolong the survival time in many patients. Because of the long-term period with symptomatic brain tumors in this disease, the patients should be treated even in the presence of multiple metastases in other organs.

救急医療体制の確立とともに突然心停止し,心肺停止状態で救急医療施設に搬入されるCPAOA例が増加している。急性心筋梗塞発症早期に突然死が多いとされるが,入院前心停止例では正確な臨床診断は難しく,病理解剖でも発症6時間以内では特徴ある所見に乏しい。目的:成人内因性突然死における急性心筋梗塞の頻度と発症直後に突然心停止した心筋梗塞超急性期の病態を明らかにする。症例・方法:最近7年間に当部へ搬入された30～80歳の内因性CPAOA384例のうち臨床診断で「急性心不全」が212例(55.2%)を占めた。このうちの64例に剖検を行い,剖検時冠状動脈造影を含め冠状動脈ならびに心筋病変を検討した。急性心筋梗塞の診断は冠状動脈の血栓性閉塞・狭窄所見を重視し,病変灌流域心筋組織のhematoxylin-basic-fuchsin-picric acid染色陽性所見を参考とした。結果:64例中急性心筋梗塞は36例(56.3%)で,27例に内膜破綻と新鮮血栓,6例に内膜破綻がみられた。初発心筋梗塞19例,陳旧性梗塞再発例17例で,前者の6例,後者の12例が重症多枝病変例であった。冠状動脈閉塞・狭窄病変は主要冠状動脈中枢側に多かったが,とくに一枝病変例18例では各枝いずれも中枢側に責任病変があった。他は不整脈死6,大動脈瘤破裂6,心筋症4,肺塞栓症2,その他7,不明3例であった。考案・結語:「急性心不全」とされた成人内因性CPAOA64例の剖検で急性心筋梗塞が36例,56.3%を占めた。これを「急性心不全」212例にあてはめて推定した例に臨床診断で急性心筋梗塞と診断し得た20例を加えると成人内因性CPA症例384例中で急性心筋梗塞の頻度は36.2%と推定された。心筋梗塞超急性期突然死例のうち初回発症例では一枝病変例が,再発例では重症多枝病変例が多く,また一枝病変突然死例では各枝中枢側に病変を有することが示された。