人工呼吸法のひとつであるhigh-frequency ventilation (HFV)のうち,high-frequency jet ventilation (HFJV)の気道温度に及ぼす影響と気道加湿方法の問題点を明らかにするために基礎的検討を行った。方法:HFV ventilatorをチムニーピースを介しテスト肺と連結し,いわゆるジェット方式(open system)においてジェット駆出頻度を3から40Hzへ,駆動圧を0.25から3kg/cm²へと変化させて気道温度の指標として,テスト肺内温度の変化を記録した。さらに,チムニーピースより加湿用の生理食塩水を5ml/hrおよび10ml/hrにて滴下しテスト肺内温度の変化を観察した。結果および考察:HFV ventilator作動後,すべての条件下でテスト肺内温度は上昇し,チムニーピースのジェット流の噴出部は加熱されていた。とくに駆動圧3kg/cm²,駆出頻度10Hzの条件下では温度上昇は最高7℃に達した。また,各条件下の分時駆出量と温度上昇との間の相関係数は0.45であった。この温度上昇は空気噴出部で生じた間欠流による摩擦熱発生の結果と考えられた。水分滴下法での加湿によって肺内温度は急激に低下し,駆動圧・駆出頻度にかかわらず滴下速度5ml/hrおよび10ml/hrでは,肺内温度の低下はそれぞれ3.3±0.1℃, 5.4±0.1℃を示した。これは加湿によって気化熱が奪われ,肺内温度が低下したためと考えられ,今後滴下水分の加温についての配慮が必要と思われた。

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急性期脳梗塞入院患者に対し,その合併心疾患について断層心エコー図法と24時間心電図を用い検討した。脳梗塞発症様式により突発完成型と緩徐進行型に分け,また大きさ・部位により大梗塞・皮質枝系梗塞・穿通枝系梗塞・小脳梗塞・脳幹梗塞と分類した。患者の病型別内訳は総数174例のうち,突発完成型44例(25%),緩徐進行型130例(75%)であり,一方,大きさ・部位別では,穿通枝系梗塞が97例(56%)と過半数を占めた。心エコー所見;心エコーを実施した158例中,弁膜症・心筋梗塞・心筋症・左房拡大・左房左室内モヤモヤエコー・左房内血栓の合併は,突発完成型で19例(43%),緩徐進行型で17例(15%)と有意に前者に多かった。これは,前者に心原性脳塞栓症が多い可能性を示唆する。正常範囲内の所見は,突発完成型と緩徐進行型の間に有意差はなく,両型合わせて81例(51%)で,約半数に心エコー上異常所見を認めなかった。24時間心電図所見;24時間心電図を施行した104例中,突発完成型,緩徐進行型の間に差異が認められたのは,心房細動の合併率である。前者は9例(32%)に,後者は7例(9%)に合併しており有意差が認められた。また両型合わせた16例(15%)の心房細動合併は,一般成人0.4%の出現率に比し有意に高かった。洞不全症候群の早期診断に寄与した症例もあった。正常範囲内所見は,突発完成型9例(32%),緩徐進行型32例(42%)の間で有意差はなく,両型合わせると41例(39%)であった。以上をまとめると,1)脳梗塞患者は,その病型を問わず,約半数に心エコーあるいは24時間心電図上の異常所見の合併を認めた。2)弁膜症,心筋梗塞,心筋症,左房拡大,左房左室内モヤモヤエコー,左房内血栓の合併は,突発完成型脳梗塞に有意に多かった。3)心房細動の合併率は,脳梗塞患者に有意に高く,しかも突発完成型にはさらに高かった。脳梗塞の急性期に心疾患との合併を重視し,これを早期診断することは,脳梗塞治療成績の改善および再発の予防につながると思われた。

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A rare patient who had rapid spontaneous resolution of an acute subdural hematoma caused by boxing is reported. On admission a CT scan showed a subdural hematoma containing a low-density area over the left cerebral hemisphere. The subdural hematoma had disappeared on a CT scan taken 1 day after the injury. But magnetic resonance imaging showed that the subdural hematoma was not completely resolved. The hematoma was detected diffusely covering the cerebral convexities and the left side of the tentorium. The outcome was good with nonsurgical treatment. We present this case and discuss the mechanisms of rapid resolution of acute subdural hematoma.

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A case of head injury with rhabdomyolysis during thiamylal therapy is reported. The total dose of thiamylal was 489mg/kg, which was higher than that in the usual barbiturate therapy. The blood concentration of thiamylal seemed to be more than 10mg/dl on the CPK max-day, and without plasma exchange, CPK and s-Mb were decreased within 24 hours after stoppage of the thiamylal treatment. This suggests that the cause of this rhabdomyolysis was not pressure necrosis, arterial occlusion nor infection, but thiamylal intoxication. The mechanism of this rhabdomyolysis seemed to involve an abnormality of cell membrane function induced by thiamylal intoxication.

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We report a case of Aeromonas hydrohila septicemia in a previously healthy and non-immunocompromised patient without any trauma. The onset was sudden with symptoms resembling acute deep vein thrombosis. Shortly, the patient suffered progressive myonecrosis and gas gangrene with rapid fatal outcome. A 55-year-old man noticed left elbow pain 12 hours prior to admission. The left upper extremity was diffusely swollen with several hemorrhagic bullae on the dorsum of the hand and forearm. Angiographic findings revealed no obstructive changes in the vein. Despite the intensive therapy, his general condition progressively worsened, and gas production with a foul odor began. With the diagnosis of gas gangrene, disarticulation of the left upper extremity was performed. Postoperatively, the patient became hypotensive without response to intravenous fluid and cathecholamines and he died 24 hours after admission. Aeromonas hydrophila was identified from samples of arm muscle and blood obtained at the operation.

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Early diagnosis of phlebothrombosis of the superior mesenteric vein is difficult, and in most cases this condition must be treated by enterectomy. The patient, a 56-year-old male with no past history of phlebothrombosis, was brought to the hospital with a chief complaint of abdominal pain. Angiography led to a diagnosis of phlebothrombosis of the superior mesenteric vein, and fibrinolytic agents were therefore administered via a catheter placed in the superior mesenteric artery. Following partial enterectomy on the 10th day, a catheter was inserted into the superior mesenteric vein. Continuous fibrinolytic therapy was effective in preventing postoperative recurrence; dissolution of the phlebothrombosis in the portal vein was also observed.

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A rare case of brain stem infarction as a complication of cervical spine injury is reported. A 15-year-old male had sustained a cervical spine injury complicated by quadriplegia. Cervical X-ray and CT scan revealed a right facet dislocation at C4/5. Ten hours after open reduction of the dislocation, he developed cranial nerve deficits. Vertebral angiograms showed complete occlusion of the basilar artery at its origin and of the right vertebral artery. Brain MRI demonstrated infarction of the medulla and pons. The fact that a follow-up angiogram revealed intimal injury of the right vertebral artery suggested embolization of the basilar artery originating at the initial site of injury of the vertebral artery. Vertebral artery injury may be a common lesion following cervical trauma. Consequently, the possibility of secondary infarction of the brain stem or cerebellum should be taken into consideration in managing patiens with cervical spine injuries.

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Two cases of severe gastrointestinal hemorrhage caused by cytomegalovirus (CMV) infection are reported. Case 1: The patient had massive hematochezia caused by a CMV infection of the stomach and ileocecal region during steroid therapy for the treatment of interstitial cystitis. Surgery and the intra-arterial pitressin stopped the hemorrhage, but the patient subsequently died due to multiple organ failure. Case 2: While undergoing postoperative chemotherapy for a tumor of the testis, the patient developed Candida sepsis as a result of agranulocytosis, whereupon massive diarrhea and hematochezia occurred because of a CMV infection of the duodenum. Surgery, however, stopped the hemorrhaging, and the patient recovered favorably and was released from the hospital. CMV is liable to cause increased pathological changes in the gastrointestinal tract, and this should be anticipated even by those in the field of emergency and critical care medicine. Hence, it is necessary to be knowledgeable about CMV infections so that a precise diagnosis can be made.

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