Background and Objective: The 2004 Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock (SSCG), which are the first evidence-based international guidelines, advocate a large volume of initial fluid resuscitation, but its importance has not been well substantiated. We aimed to validate the importance of initial fluid therapy and to clarify the required infusion volume. Methods: We examined 64 patients with severe sepsis or septic shock who were transported by ambulance and admitted to the International Medical Center of Japan between January 1, 2001 and August 31, 2006. The patients were separated into survivors and non-survivors at 72 hours and at 28 days after admission. We compared severity at the time of admission and treatment recommended by the SSCG. Results: Survivors at both 72 hours and 28 days were infused with significantly more fluid than non-survivors. Severity at the time of admission to hospital and other strategies such as antimicrobial therapy or vasopressor administration did not significantly differ between the groups. The survival rate was 100% when the volume infused at 1 hour after admission was over 1,700 ml. Even when the volume was below 1,700 ml at 1 hour, the survival rate was 93% when over 3,200 ml was infused over 24 hours and the 24-hour urine volume was over 550 ml. However, when the 24-hour urine volume did not reach 550 ml, the survival rate was 38%. When the infusion volume was less than 1,700 ml at 1 hour and less than 3,200 ml at 24 hours, the survival rate was 82% if the 24-hour urine volume was over 550 ml. However, when the 24-hour urine volume was below 550 ml, the survival rate was 36%. Conclusion: We confirmed the appropriate volumes of initial fluid therapy required to maintain organ perfusion, and that the indicators of infusion volume shown in the SSCG are valid.

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Background: The epidemiologic data for the vital signs and severity (developed by Yasuoka) in patients with heat illness from the prehospital site to the hospital have rarely been reported. Objective: To elucidate the features of exertional and classic heat illness, respectively, and to assess the severity-related factors. Methods: The data of patients suffereing from heat illness in Yamaguchi Prefecture between July 1 and August 31 in 2006 were collected in cooperation with the emergency medical service (EMS) and the prefectural medical association. They were analyzed based on the severity of heat illness. Results: Three hundred thirty-nine patients were transported by ambulance and 92 patients (27%) were matched with the data obtained from the hospitals. The data of 90 patients, except for 2 cardiopulmonary arrested patients, were thus analyzed. Concerning the causes of heat illness, there were 65 patients presenting with exertional heat illness, 24 patients demonstrating classic heat illness and 1 patient whose illness was unknown. The patients with classic heat illness were significantly older, less frequently male and showed a significantly lower oxygen saturation at the prehospital site. In addition, there was also a trend toward a lower rate of grade III illness at the hospital among the patients with classic heat illness. When comparing between grade I/II (n = 52) and grade III (n = 38) cases at the hospital, the patients with grade III illness were more frequently male, showed a significantly lower systolic blood pressure at the prehospital site and the hospital, and also tended to be hospitalized for a significantly longer number of days. There was a trend toward a higher rate of outdoor incidence or exertional heat illness among the grade III cases. Being older than 50 years of age, being a male, and demonstrating both exertional heatillness and a lower systolic blood pressure at the hospital were all identified to be independent predictive factors for grade III illness. Conclusions: Based on the above findings, the risk factors for severe heat illness, namely an age of older than 50 years, being a male, and demonstrating both exertional heat illness and a lower systolic blood pressure at the hospital were thus identified.

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A 69-year-old male was transferred to our department in a state of shock and circulatory collapse. Contrast enhanced computed tomography showed a bilateral common iliac aneurysm and the early enhancement of a dilated inferior vena cava. In addition, iliocaval fistula was diagnosed by aortography. Although sudden cardiac arrest occurred before performing an emergency operation, a recovery of the spontaneous circulation was observed after about 15 minutes of cardiopulmonary resuscitation. A surgical closure of the fistula with graft replacement was successfully performed, followed by a reduction of the cardiac output (10 to 4.6 l/min) and the central venous pressure (28 to 12 mmHg). Unfortunately, however, anoxic encephalopathy occurred due to cardiac arrest. Arteriocaval fistula is one of the rare complications of an aortic aneurysm rupture. Varying degrees of clinical symptoms are observed depending on the size of the fistula and the duration of the disease, which thus makes an accurate diagnosis of such an iliocaval fistula very difficult. Recent studies recommend the use of multidetector row angio-CT for the preoperative comfirmatory diagnosis of a fistula. Due to the extremely high mortality rate associated with a direct surgical repair of the fistula, endvascular treatment has therefore recently been adopted. It is therefore important to evaluate the hemodynamic changes carefully in patients presenting with a large iliocaval fistula during the perioperative state.

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A 93-year-old man was admitted to our emergency room in a coma (Japan Coma Scale 200). He was reported to have been exposed to the air outside for approximately 4 hours at a temperature around 10°C. On examination, he was found to be in a collapsed state with arrhythmia accompanied by atrial fibrillation and multiple premature ventricular contractions on cardiac monitor. His body temperature could not be taken with an ordinary thermometer. Severe acidosis was also found on arterial gas analysis. Profound hypothermia was assumed and core rewarming was performed with continuous hemodiafiltration (CHDF) using warmed dialysis fluid. As his hypothermia and acidosis improved, the creatine kinase (CK) value rose rapidly, which was considered to be suggestive of rhabdomyolysis. Two and a half hours after CHDF commencement, consciousness level improved to JCS-2 and the CK decreased enough to prevent acute renal failure. CHDF was discontinued at 33 hours after commencement of therapy. He was discharged from the ICU on the 4th day of hospitalization. Conculusion: Core rewarning using CHDF in an acute phase for accidental hypothermia of a very old patient with severe acidosis, was useful concerning prevention of acute renal failure following rhabdomyolysis.

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A 63-year-old female was admitted to our Emergency Department 18 hrs after ingesting 0.9 L of distilled white liquor and about 150 ml of liquid fertilizer (Hyponex^®), in an attempted suicide. Hyperkalemia and methemoglobinemia (arterial methemoglobin 25.6%) were present. Following admission, the level of methemoglobin gradually decreased and at 12 hrs after admission, the level had returned to normal. The patient was discharged on the third day of hospitalization. Deaths due to Hyponex? have been reported but there have been no reports of it leading to the development of methemoglobinemia. Methemoglobin is produced when nitrates are reduced to nitrites within the body. We suspected oxidation of hemoglobin to methemoglobin by nitrates within the blood. Reports of poisoning by liquid fertilizer are uncommon, but caution is advised because there is the possibility that it may lead to methemoglobinemia.

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