Sepsis and related problems continue to be major causes of death. Recently, with progress in the investigation of cytokines and other humoral mediators, the concept of sepsis has changed. This article reviews animal models of sepsis and septic shock, according to the definition of sepsis, which was decided by the ACCP/SCCM consensus conference committee in 1992. We classified sepsis and septic animal models as follows: (1) soft tissue abscess model, (2) bacteremia model, (3) peritonitis model, (4) endotoxemia model, (5) organisms other than GNR model, (6) humoral mediator model. We discuss, and evaluate these models in this paper. For relevant animal models, we make some proposals. 1) It is important that they adequately replicate the features of the sepsis in humans, which is characterized by a hyperdynamic and hypermetabolic state. 2) Considering SIRS and other new concepts related to sepsis, positive bacterial culture of the blood is not necessary for verification of the septic state. 3) Detailed monitoring like measuring of CO or MR is indispensable to a sepsis model, because sepsis and septic shock have a different hemodynamic and metabolic state in every phase.

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Parenchymal lesions in the complicated hematoma type of traumatic acute subdural hematoma consist of cerebral contusion and diffuse axonal injury as primary injuries and brain edema, acute brain swelling and resulting hypoxic and ischemic changes as secondary insults. In hematoma irrigation with trephination (HIT) therapy, after the subdural hematoma was removed with trephination and washing out by injection of saline into the hematoma cavity, these parenchymal pathological processes were managed conservatively with intensive care tactics, often under barbiturate-induced coma for the control of intracranial hypertension. In this study HIT therapy was reexamined and evaluated in comparison with large decompressive craniectomy (LDC) therapy in which postoperative tactics to increase intracranial pressure were medically the same as those after HIT. HIT and LDC were intentionally performed consecutively in 68 cases in the University of Tokyo Hospital and in 52 cases in Showa General Hospital, respectively. In the group scoring 30 to 200 on the Japan coma scale (JCS) on admission, LDC demonstrated a higher survival rate than HIT. According to the rotational acceleration-deceleration mechanism producing diffuse cerebral injury, the severest shearing strains are observed in brain surface and stem. The mechanism induces subdural bleeding at its maximum. HIT is reasonable in cases with minimal brain swelling, but at present pathophysiolosical analyses of the parenchymal process are not available in the clinical setting. In most cases that lack sufficient time until transportation to the operating theater, the strategy of emergency trephination at the emergency room and intracranial pressure monitoring followed by barbiturate administration and/or LDC is recommended for the management of acute subdural hematoma with diffuse cerebral injury.

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To elucidate the mechanism of remarkable anemia observed in brain-dead patients that are maintained for a long period, we investigated hematopoietic function after brain death. Brain-dead patients from severe closed head injury without distinct external hemorrhage were studied for myelogram, peripheral blood picture and erythropcietin before and after brain death. Brain-dead patients were maintained with the combined administration of arginine vasopressin and catecholamine. After brain death hemoglobin fell by approximately 4mg/dl, and remained low thereafter. The erythropoietin value was 50.2±19.4mU/ml, which was above the normal range, suggesting that brain-dead patients secreted as much erythropoietin as patients with anemia from other causes. Reticulocyte count was (8.8±4.3)×10⁴/mm³ until 20 days after brain death, but increased remarkably from 21 days after brain death to as high as (25.5±14.6)×10⁴/mm³. Platelet count fell transiently after brain death, then recovered to the normal range at 10 days after brain death, and remained above the normal range thereafter. In myelogram, myelocytes increased significantly in the infection group and non-infection group within 7 days after brain death. Although there was no significant difference between these groups, the segmental form tended to increase in the non-infected group from 8 days after brain death. Brain-dead patients received fluid with a positive water balance of 2, 000ml/day to maintain hemodynamics immediately after brain death. The present study suggests that anemia after brain death is caused by the dilution effect of fluid resuscitation and slow response of erythrocyte production, and that bone marrow function is maintained after brain death.

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The present study, the first of its kind in Japan, looks at the problems involved in the transport of emergency patients by helicopter and fixed-wing from the standpoint of physicians working on remote islands. In October of 1991, questionnaires covering clinical setting, reasons for transport, flight physicians and transport cases were mailed to 200 physicians who practiced, or had practiced on remote islands in 6 regions: Hokkaido, Tokyo, Shimane, Nagasaki, Kagoshima and Okinawa. Ninety-four of them (47.0%) filled out and returned the question-naires to us. Most physicians working at the scene (68.1%), reported that they had good communication with physicians at the base hospitals. Furthermore, some of them (33.0%) had been trained at the base hospitals.Respondents on islands near Nagasaki or Hokkaido reported that they had clearly defined criteria for requesting patient transport. In Nagasaki especially five clinical situations were defined; maternal states expected to result in delivery of immature newborn, congenital heart diseases in need of emergency surgical treatment, and others. Physicians working at small clinics on small islands in Tokyo, Kagoshima and Okinawa, sometimes request emergency transport for cases, in which diagnosis was not possible and in need of long-term hospital care. Fifty-six physicians (59.6%) reported nighttime and foul weather as the main obstacles to patient transport and many respondents suggested that construction of heliports at the base hospitals would shorten transport time. Also, 71 physicians (75.5%) emphasized the question of the safety of the flight physician. Since treatment of patients during transport is practically impossible at present, transport helicopters specially equipped for medical emergencies should be made available if physicians are to accompany the patients during transport. Various problems in 76 actually transported cases and 37 untransported cases were reported. In these cases, respondents pointed out that weather conditions, changes in the patient's clinical state, and the complexity of the procedure for having patients accepted by hospitals, sometimes presented obstacles to emergency transport.

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Nineteen cases of international repatriation were reviewed in terms of organizing a support system in Japan. Twelve patients were inbound repatriated Japanese and 7 were outbound evacuated foreigners. The destinations ranged over 13 countries on the European, North and South American, Asian, and Oceanian continents. The average flight mileage and flight hours were 7, 034km and 9:02, respectively. The longest transport was a mission from Lima in Peru, via Los Angeles, which took more than 21 flight hours. In all cases, scheduled commercial flights were employed. All repatriations were conducted uneventfully and no obvious medical obstacles were encountered on the way. Neither jet noise, take off acceleration and landing deceleration, nor flying vibration affected the physical condition of the patients remarkably. The transfer cost around 3 million yen per case on average. Arrangements and support by international assistance companies were beneficial in 10 cases. In addition to proper medical judgment, cooperation and liaison with counterpart doctors, ambulance services, flight carrier companies, insurance companies and attending physicians were also crucial in planning and executing international repatriation. While the international repatriation service is well established in European countries, it remains to be organized in Japan and warrants consideration in this regard.

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A case of traumatic bile duct stenosis treated with an expandable metallic stent (EMS) is reported. A 48-year-old man was admitted with hemorrhagic shock caused by hepatic trauma. Several days after emergency surgery to repair of the hepatic laceration, he showed jaundice and leakage of bile on abdominal CT. Thirty days after admission, PTCD was performed to reduce the intrabiliary tract pressure. Two months later, remarkable stenosis was detected at the common bile duct, although the leakage of bile was decreased. We inserted the EMS (“Strecker” stent) through the PTCD to improve common bile duct stenosis. This improved bile flow, and no side effects were recognized during the one-year observation period. Recently, EMS has been used for obstructive jaundice mostly associated with malignant lesion, and many benefits have been reported compared mith usual biliary endoprosthesis. EMS might also be useful for traumatic biliary tract stenosis without operative invasion.

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A 49-year-old man went into deep shock soon after an intravenous injection of Neurotropin^® and was referred to our medical center. He developed cardiac arrest in the ambulance about 7 minutes before arriving at our center. Cardio pulmonary resuscitation was performed for about an hour in the emergency room, but ventricular fibrillation (VF) was sustained. The emergency percutaneous cardio pulmonary support system (PCPS) successfully resuscitated the patient and maintained general circulation. The refractory VF indicated the presense of ischemic heart disease. Coronary angiography (CAG) under PCPS support showed a marked spasm on the proximal site of the coronary arteries. We suggest that the refractory VF was related to the coronary spasm induced by anaphylactic reaction. He was soon weaned from PCPS and discharged without any remaining neurological deficits. Emergency application of PCPS could improve the survival of cardiac arrest.

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We report a case of acute permeability pulmonary edema after the transfusion of fresh frozen plasma (FFP). The patient was a 68-year-old female who was transferred to our hospital for the treatment of subarachnoid hemorrhage. After clipping the aneurysm in the left middle cerebral artery, the patient developed a bleeding diathesis. Laboratory findings confirmed disseminated intravascular coagulopathy (DIC). After the transfusion of FFP to treat the DIC, the febrile attacks recurred and were reduced by corticosteroids. At the time of the last febrile episode, dyspnea and hypoxia suddenly developed. The chest X-ray revealed alveolar opacities in the right upper and middle lung field without heart enlargement. The ultrasound cardiogram was normal. Based on the clinical course, the acute clinical features were considered to represent non-cardiogenic permeability pulmonary edema. Anti lymphocyte antibody was detected in the patient's serum. The leucoagglutination reaction was confirmed between the patient's serum and the FFP used on the day when the acute pulmonary edema occurred. Therefore, this reaction suggested the allergic permeability pulmonary edema. To prevent pulmonary edema after the transfusion of FFP, the use of a leucocyte reduction filter is considered effective in reducing the leucoagglutination reaction.

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A 68-year-old woman with an infected cutaneous fistula went into cardiac arrest during fistulography. This event occurred shortly after an inadvertent injection of barium sulfate into the cutaneous fistula subsequent to barium enema examination. X-ray films of fistulography revealed the entrance of the contrast agent into the inferior vena cava. Although the exact mechanism of intravasation remains unclear, the pressure in the fistula may have increased remarkably upon the injection of barium sulfate, resulting in the contents entering into venous drainage. Disseminated intravascular coagulation associated with apparent bleeding tendency occurred after the episode. However, pulmonary oxygenation was not greatly deteriorated and a perfusion lung scan failed to reveal pulmonary embolism that might have contributed to cardiac arrest. Another possible explanation for the abrupt collapse is the simultaneous intravasation of endotoxin or other toxic substances from the infected fistula or in the barium suspension. Therefore, we should be aware of the development of this complication at fluoroscopy, especially on the injection of contrast agent into a fistula that might have been infected with bacteria.

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