Therapeutic medical gas is pharmaceutical gaseous molecules which offer solutions to medical needs. In addition to traditional medical gases including oxygen and nitrous oxide, a number of medical gases have been recently discovered to play protective roles in various disease conditions. In particular, nitric oxide, carbon monoxide, hydrogen sulphide and hydrogen are found to be endogenously generated in human body and mediate signaling pathway as biological messengers, and shown to have potent cytoprotective effects. These gaseous agents were referred as “signaling gaseous molecules” and recently have come to the forefront of research. Acute respiratory distress syndrome (ARDS), a diffuse heterogeneous lung injury characterized by hypoxemia, non cardiogenic pulmonary edema, is caused by various etiologies including local/systemic inflammation and oxidative stress. Recently, the potent antioxidant and anti-inflammatory effects of hydrogen gas were discovered and a number of experimental studies have shown hydrogen gas can prevent ARDS. Medical gases can be administered in a straightforward way simply by providing the gas for the patients to inhale using a ventilator circuit. The ability to administer medical gas inhalationally makes it extremely attractive from a feasibility standpoint for translation into a human clinical setting. Herein, we summarize the recent advances of therapeutic medical gas research and discuss their clinical feasibility, typically such as nitric oxide, carbon monoxide, hydrogen sulfide, and hydrogen. Although further investigations are required, medical gas may provide a huge impact as a novel and innovative therapeutic tools for ARDS in emergency/critical care medicine.

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Warfarin is commonly used for the prevention and treatment of thromboembolism. However, anticoagulation with warfarin carries an increased risk of intracranial hemorrhage (ICH), which is more often fatal than is spontaneous ICH, although vitamin-K preparation and fresh frozen plasma (FFP) produce significant PT-INR correction within several hours. However, immediate reversal of anticoagulation is achieved with a prothrombin complex concentrate (PCC). We prescribed a PCC for patients with warfarin-associated ICH and examined the effects of PCC. The PCC group comprised 12 patients with warfarin-associated ICH and a PT-INR ≥1.5 at the time of diagnosis, for whom prescription of PCC for correction of anticoagulation was considered. PT-INR was measured on the day of onset of ICH, 10 minutes after the administration of PCC, and on the day following onset. Seven patients with warfarin-associated ICH in whom coagulation was corrected by a vitamin-K preparation and/or FFP before reversal of anticoagulation with PCC was incorporated into our protocol comprised the Control group. The amount of FFP administered within 24 hours of warfarin-associated ICH was 983±818ml in the control group and 193±286ml in the PCC group. In this study, administration of PCC resulted in a significant reduction in the dose of FFP required for correction of coagulability (p<0.05). As indicated by the change in PT-INR following administration of medicine to reverse anticoagulation, treatment with PCC reversed anticoagulation quickly (pretreatment PT-INR: 2.94±1.14 vs 10 minutes after administration: 1.60±0.28). There was no significant difference in 30-day outcomes (Glasgow outcome scale) between the two groups. Although no significant effect on improvement of 30-day outcomes was observed with PCC administration in this study, the PT-INR values were improved quickly and dramatically, which suggests an effect of lowering medical costs associated with the use of FFP. Since the content of coagulation-factors of commercially available PCC varies with brands, a randomized controlled trial would be needed to establish the guideline for the management of warfarin reversal with PCC specific to Japan.

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Depression is well known to contribute to ischemic heart disease (IHD) development. However, IHD is difficult to diagnose in the critical care setting because symptoms are masked when combined with depressive manifestations. We assessed the associations between depression and factors involved in lifestyle-related diseases. The study population was 397 consecutive patients with mental disorders, seen in our emergency room (ER) between May 2009 and May 2010. We analyzed patients with depression (n=269) as compared to other mental disorders (n=128) (Schizophrenia [n=116], Anxiety neurosis [n=8], Dissociative disorder [n=4]) in terms of individual background factors (age, gender, systolic and diastolic blood pressures, any history of IHD, hypertension, diabetes mellitus, hyperlipidemia), white blood cell count and C-reactive protein using logistic regression. When adjusted for age, the hypertension rates were significantly higher in patients with than in those without depression (40.6% vs. 19.7%; p=0.009). In a multivariate analysis, history of hypertension was independently associated with patients with and without depression (p=0.045; odds ratio, 1.97 [95% CI, 1.01-3.89]). Furthermore, the risk of moderate cardiovascular events was significantly higher in hypertensive patients with depression than in hypertensive patients without depression (34.6% vs. 13.0%, p<0.001). In conclusion, the results suggest that depression is significantly frequently accompanied by hypertension and that patients with depression need to be managed as those at an elevated risk for cardiovascular disease.

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Purpose: This is a retrospective comparative study about neurological outcomes of comatose patients after out of hospital cardiac arrest (OHCA) due to ventricular fibrillation (VF) who presented before and after implementation of comprehensive post-cardiac arrest care including therapeutic hypothermia (TH) and immediate coronary angiography (CAG) in a community hospital.
Subjects and Method: We evaluated 26 comatose survivors with reactive pupils or spontaneous breathing (Before April 2008 when we have started to implement the TH and immediate CAG, we defined Pre-TH patients and assigned 14 patients.Thereafter, we defined Post-TH patients and assigned 12 patients) among 52 consecutive OHCA due to VF cases from December/1/2003 to May/31/2011. In Post-TH patients, an immediate CAG was always performed to decide the indication of percutaneous coronary interventions (PCI) followed by active surface cooling to achieve a rectal temperature of 34°C. The primary outcomes were length of stay, mortality, the neurologic outcome after 1 month, the rates of hospital procedures (CAG, PCI, etc) and complications. The secondary outcomes were the comparison of the frequency of acute coronary syndrome, interventions and complications between the favorable (CPC: Pittsburgh cerebral performance category 1-2) and non-favorable neurologic outcomes (CPC 3-5). All data were compared using Fisher’s exact test or Student’s t-test.
Results: The rate of favorable neurologic outcome significantly improved in the Post TH patients (p<0.05), the mortality rate was not significantly different (p=0.13). The rates of CAG performance and intra-aortic balloon pumping (IABP) use were higher in the Post-TH patients (p<0.05). The rate of pulmonary edema alone was lower in the Post-TH patients (p<0.05) among complications. As for neurological outcomes, the frequency of TH and immediate CAG was higher (p<0.05) and that of pulmonary edema was lower (p<0.01) in the favorable outcome.
Conclusions: The comprehensive post-cardiac arrest care including TH, CAG and IABP could be associated with a significant improvement in neurologic outcomes and reduction of the complication of pulmonary edema in comatose survivors whose initial rhythm was VF.

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A 71-year-old female had cardiopulmonary arrest after aspirating confectionery products. Immediate cardiopulmonary resuscitation (CPR) using a bag valve mask and chest compression resulted in resumption of respiration and heartbeat after 10 minutes. The patient was transported to our hospital because of altered consciousness. Her abdomen was distended. Plain X-ray revealed right subphrenic free air. Computed tomography revealed large amount of free intra-abdominal air. We suspected gastrointestinal perforation and performed emergency laparotomy. The lesser curvature of the stomach was red, with small air bubbles in the serosa. An incision was made in the anterior stomach wall, confirming a 7 cm gastric mucosal laceration. Although we confirmed that the laceration did not penetrate all gastric wall layers, a small part of it was presumed to have caused intra-abdominal air accumulation. We performed abdominal lavage and inserted a drain. The patient improved postoperatively and was transferred to a different hospital after 16 days. During CPR, the risk of gastric rupture increases because of gastric dilation during chest compression and inappropriate ventilation. Furthermore, if abdominal distension or signs of peritonitis are observed when heartbeat resumes, gastric rupture should be suspected and rapidly diagnosed by preoperative imaging. And it is important that laparotomy is performed immediately.

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Ulcerative colitis (UC) is an inflammatory bowel disease. One of the features of UC is that the inflammation is localized in the colorectum. The inflammation, however, can spread past the ileocecal valve, a condition called backwash ileitis (BI). It is rare to observe the end of the ileum by endoscopy during the aggravation phase in severe UC. The initial diagnosis of BI often occurs during surgery. In this report, we present the case of a 26-year-old male who had been diagnosed with UC seven years previously. Once it became severe, he was treated with a steroid. He eventually developed panperitonitis due to intestinal perforation. Because there were multiple perforations of the ileum, a partial excision of the small intestine was performed. A second procedure, a total colectomy, was performed after the patient developed melena. Upon pathological inspection, a characteristic of UC was found in the excised ileum. Ileal perforation as a result of severe UC combined with BI is very rare. The treatment in a case such as this, for peritonitis caused by ileal perforation as a result of BI, is limited to the partial excision of the small intestine, which preserves the colon. However, it seems that a total colectomy should have been performed, considering that the postoperative melena of the colon had continued.

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