【目的】外科的侵襲が免疫能に与える影響を評価するために末梢血中CD4⁺ヘルパーT細胞(Th) 1/Th2バランスならびに単球機能を検討した。【対象と方法】2000年6月より2002年12月までの2年6か月の間に関西医科大学高度救命救急センターに入院した患者のうち広範囲熱傷5例,敗血症6例,多発外傷9例,計20例を対象とした。採取した末梢血単核球細胞にて,単球機能(エンドトキシン刺激後のIL1, IL1ra, TNF, IL10, IL6生成能およびHLA-DR陽性率)およびTh1/Th2バランス(phorbol myristate acetate+ionomycin刺激後のIFN, IL4生成能)を細胞内サイトカイン法を用いフローサイトメーターにて測定した。【結果】Th1比率は,熱傷(9.4±8.1, p<0.05 vs健常者),敗血症(6.2±2.3, p<0.01 vs健常者),多発外傷(Injury severity score≧25)(11.3±7.5, p<0.05 vs健常者)において健常者(23.1±8.1)と比べ有意な低下を認めた。一方Th2比率はいずれの病態においても健常者と比し変化を認めなかった。単球におけるHLA-DR陽性細胞もいずれの病態においても有意に低下していた。【考察】高度侵襲下ではTh1アネルギーおよび単球機能失調にて示されるように免疫不全状態に陥っていることが示唆された。とりわけ敗血症において免疫不全の傾向が強く認められたことなどより,侵襲後の免疫不全が二次感染発症に関与している可能性がある。

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A 72-years-old male consulted our hospital for oro-nasal bleeding after surgery for pharyngeal cancer. Systolic blood pressure was 62mmHg, suggesting shock. Neither gauze packing nor insertion of a Bellocq tampon was effective, and we considered that the source of bleeding was the pharynx. Hemostasis for pharyngeal bleeding was difficult, and a Sengastaken-Blakemore tube (S-B tube) was used. The tube facilitated bleeding control, and the circulatory kinetics became stable. Angiography revealed extravascular leakage. Coiling of the left external carotid artery was performed, but complete hemostasis was not achieved without the S-B tube. The inserted S-B tube was dilated for 16 hours, and then removed after hemostasis was confirmed. After removal, no additional bleeding occurred. The S-B tube was useful for achieving hemostasis for oro-nasal bleeding.

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Cardioreversion of ventricular fibrillation (VF) is one of the major targets in the therapeutic strategy for cardiac arrest. We report a case in whom intra-aortic balloon pumping (IABP) effectively treated VF caused by submersion and in whom the neurological outcome was relatively good. An 18-year-old man drowned after diving into a swimming pool. When he was rescued after 12 minutes, he was in cardiac arrest. We started advanced cardiovascular life support just after his arrival at our emergency and critical care center. The electrocardiogram revealed VF. Despite applications of direct current defibrillation and administration of vasopressin and nifecarant, VF occurred repeatedly. After we started IABP, his cardiac rhythm and vital signs stabilized. X-ray examinations revealed a cervical spine injury and severe pulmonary edema. Normothermia therapy and IABP support were performed, and high dose methylprednisolone therapy was also carried out for the cervical spine injury. Under this intensive care regimen, the patient's status improved. His Glasgow outcome scale was severe disability on discharge from our hospital. We believe that IABP is one of the effective therapies in a patient with intractable cardiac arrhythmia. In addition, IABP may be effective for maintenance of cerebral blood flow after cardiopulmonary resuscitation.

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We report a patient with pulmonary hypertension complicated with pneumonectomy in blunt traumatic injury to the bronchus successfully managed by percutaneous cardiopulmonary support (POPS). A 4-year-old girl injured in a traffic accident was transferred to our hospital. She had thoracic injury with respiratory failure, and we diagnosed bilateral hemopneumothorax. Despite insertion of bilateral chest tubes and intubation, the left lung was not inflated, showing continued massive air leakage. Pneumonectomy of the left lung was performed for the left main bronchial injury. After the operation, PCPS was started because of pulmonary hypertension associated with deteriorated hemodynamics and oxygenation. Following this, the respiratory and hemodynamic states became stable. PCPS was continued for 5 days and the ventilator was needed for 11 days. The patient was discharged on day 52. We considered the pneumonectomy, contralateral lung contusion, drugs, hypoxic pulmonary vasoconstriction, and ventilator as causes of pulmonary hypertension. PCPS is one of the useful treatments for severe chest trauma.

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